Role Title: Medical Auditor
Role Purpose Summary: Responsible for conducting medical claim audits to validate the accuracy and proper adjudication outlined in the Medical Plan's scope of cover.
Key Responsibilities and Accountabilities:
- Ensure proper enrollment of the Membership census as received from underwriting team in medical claims system/TPA, addition and deletion including the needful documentation.
- Auditing of medical claims, TPA for contractual obligation, which includes agreed level of service, claim processing and agreed TAT of the contracts. This auditing is frequently and randomly.
- Receive and review the escalated claims and recommend the solutions to the Line Manager.
- Provide the data/report to the concerned department.
- Review the appropriate Data and Reports from TPA on a timely basis.
- Process the Medical provider payments, reimbursement claims on the system and forward them to the finance department within the agreed time frames.
- Prepare the monthly, quarterly and annual reports within the agreed TATS' and submitted to the Finance department for the ministry.
- Propose recommendations to the Line Manager for corrective action as well as identify areas for further consideration and improvement if any.