Job purpose To manage the end-to-end claims reimbursement process efficiently and accuratelyensuring timely claim submission, verification, adjudication, and resolution—while maintaining compliance, improving customer satisfaction, and contributing to the organization’s operational excellence. Duties and responsibilities 1. Claim Submission Initiation : The insured individual or the service provider submits a claim to the insurance company for reimbursement. Required Documentation : Policy details (policy number, coverage specifics). Proof of service or expense (invoices, bills, or receipts). Supporting documents (e.g., medical reports, repair estimates, or loss reports). Submission Channels : Claims can be submitted via online portals, email, fax, or physical mail, depending on the insurer's requirements. 2. Claim Verification and Validation Eligibility Check : Determine if the claim is within the policy coverage limits and terms. Verify that the claim type (medical, property damage, etc.) is covered under the insured's policy. Document Review : Confirm all necessary documents have been provided. Ensure the claim is free from errors, fraud, or inconsistencies. Request for Additional Information : If documents are missing or unclear, the insurer requests clarification or additional evidence. 3. Claim Adjudication Assessment of Claim : Evaluate the claim amount against the policy terms and coverage limits. Check deductibles, co-pays, and exclusions outlined in the policy. Reimbursement Calculation : Determine the payable amount after accounting for policy conditions like sub-limits, deductibles, or co-insurance clauses. Approval or Denial : Approve valid claims for reimbursement. Deny claims with proper reasoning if they fall outside policy coverage. 4. Reimbursement Processing Payment Authorization : Approved claims move to the payment stage after final authorization by the claims manager or automated systems. Payment Methods : Payments are issued via direct deposit, checks, or transfers to the insured or service provider, depending on the arrangement. Notification : The claimant receives a notification detailing the reimbursement amount, processing timelines, and any deductions applied. 5. Dispute Resolution (if applicable) Denial Appeals : If a claim is denied, the insured can appeal the decision with additional documentation or clarification. Resolution of Discrepancies : Address issues such as underpayments or errors in processing through negotiation or review. Customer Support : Insured parties can work with claims specialists to resolve questions about their claim or reimbursement status. 6. Final Documentation and Archiving Record Keeping : All claim-related documents and correspondence are archived for compliance and future reference. Regulatory Reporting : Ensure claims are processed in compliance with local, state, or federal regulations and report as needed.
