CLAIMS OFFICER

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JOB DESCRIPTION FOR CLAIMS OFFICER

JOB SUMMARY:

The Claims Officer is responsible for managing the end-to-end claims process, ensuring that claims are assessed, processed, and settled in a timely, accurate, and compliant manner. The role involves liaising with internal and external stakeholders, maintaining detailed records, and adhering to company policies and regulatory requirements. The Claims Officer is also tasked with analyzing claims data to identify trends and opportunities for process improvements.
Key Responsibilities:

  • Claims Processing and Management:
    • Review, validate, and process insurance claims following industry standards, company policies, and procedures.
    • Evaluate supporting documents to determine the authenticity and coverage under the policy.
    • Conduct investigations for claims requiring further review or verification.
    • Communicate claim decisions to stakeholders, providing clear justifications where necessary.
    • Coordinate with relevant departments to gather additional information needed for claim resolution.
  • Risk Assessment:
    • Investigate potential fraudulent claims and escalate suspicious cases to the appropriate department.
    • Assess claims for adherence to policy terms and conditions.
  • Customer Engagement:
    • Communicate with claimants, agents, and providers to gather necessary documentation and resolve queries.
    • Provide timely updates to clients on the status of their claims.
  • Compliance, Documentation and Reporting:
    • Ensure all claims are compliant with regulatory and legal standards.
    • Maintain accurate and organized records of all claim transactions.
    • Prepare detailed reports on claim trends and outcomes for management review.
QUALIFICATIONS:
    • A Bachelor’s degree in Insurance, Finance, Business Administration, or a related field.
    • Professional certification such as ACII is an advantage.
    • 3-5 years experience in claims processing or insurance operations.
    • Strong knowledge of insurance policies, procedures, and claims assessment.
    SKILLS AND COMPETENCIES:
      • Strong analytical and problem-solving skills.
      • Proficiency in claims management systems and insurance software.
      • Analytical skills for evaluating claims data and identifying trends.
      • Excellent communication and negotiation skills.
      • High level of accuracy and attention to detail.
      • Willingness to learn and adapt in a dynamic environment.
      • Ability to work collaboratively and independently under minimal supervision.
      • Strong ethical conduct and commitment to confidentiality.
      KEY PERFORMANCE INDICATORS (KPIS) and PERFORMANCE METRICS::
        • Accuracy:
          • Minimal or error-free in claims processing and documentation.
        • Timeliness:
          • Maintain turnaround time in claims processing and settlement.
        • Learning and Development:
          • Demonstration of knowledge growth through training assessments.
          • Active participation in team projects and department initiatives.
        • Compliance:
          • Adherence to internal policies and regulatory requirements.
          • Minimal to zero compliance-related errors.
        • Quality of Work:
          • Stakeholder satisfaction ratings from claimants and internal departments.
          • Quality of claim assessments as reviewed by supervisors.
        • Collaboration:
          • Effectiveness in coordinating with other departments and external stakeholders.
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