JOB DESCRIPTION
Role Title: Claims & Clinical Audit Officer
Department/Business Unit: Medical Services & Claims
Reports To: Head, Medical Services & Claims
ROLE PURPOSE
To review and audit medical claims to ensure accuracy, medical necessity, compliance with approved tariffs and benefit structures, and effective cost management, while safeguarding the quality and appropriateness of healthcare services provided to members.
KEY RESPONSIBILITIES
- Review and validate medical claims submitted by healthcare providers
- Conduct clinical audits to ensure medical necessity, accuracy, and compliance with approved tariffs and benefit structures.
- Identify billing discrepancies, duplicate claims, overbilling, and potential fraud.
- Assess medical records, diagnoses, treatment plans, and supporting documentation.
- Liaise with healthcare providers to resolve claims queries and discrepancies.
- Prepare claims audit reports and recommend appropriate corrective actions.
- Support cost-containment initiatives while safeguarding quality healthcare delivery.
INTERNAL & EXTERNAL RELATIONSHIPS
Internal: Heads of Departments, employees across all units.
External: Healthcare providers, and clients.
JOB SPECIFICATION
Education, Professional Qualification & Experience
- Bachelor's degree in Medicine, Nursing, Pharmacy, Health Information Management, or a related health discipline.
- Minimum of 2 years' relevant experience in medical claims, clinical auditing, or a related field.
Technical Competencies
- Sound knowledge of medical terminology, claims adjudication, and healthcare billing practices.
- Strong analytical, investigative, and problem-solving skills.
- Proficiency in Microsoft Office, particularly Excel.
- High level of integrity, accuracy, confidentiality, and attention to detail.
