Medical Claims Analyst

Job description

Job Description

Conduct medical claims analysis and deep-dive reviews to ensure compliance with regulations, coding rules and internal guidelines. Analyse claims data and processes to identify leakage, compliance issues, operational risks and improvement opportunities. Identify and report suspected fraud or suspicious billing, escalating to senior team members when necessary. Perform audits and reviews of claims files, processes and documentation to check accuracy, quality and adherence to standards.

Prepare clear file review and audit reports that enable managers to understand issues and implement remediation. Ensure timely communication of key findings and issues to all relevant stakeholders. Lead and coordinate regulatory, management and TPA reporting for medical claims, ensuring data quality, accuracy and timely submissions. Support day-to-day medical claims operations, including TPA management, reporting and general administrative tasks.

Monitor, track and report on TPA performance against service level agreements, including quality, cost and customer outcomes. Support TPA performance reviews and due diligence activities, including assessment of new and existing delegated claims authority arrangements. Provide data analysis and business insights using multiple data sources (reports, KPIs, scorecards, forecasts) to support internal teams, distributors and customers.

Contribute to process improvement, continuous improvement initiatives and system enhancements to increase efficiency and control effectiveness. Investigate and resolve operational issues related to medical bill review, including validation of data and system issues. Recommend solutions and action plans to address gaps, highlighting both financial and non-financial (customer/quality) benefits. Support quality audits, coaching and technical guidance to team members to maintain high standards of service and compliance.

Provide administrative and technical claims support to Claims personnel and related stakeholders. Perform any additional related tasks as assigned.