Medical Claim Manager

Job Description:

We are seeking an experienced Medical Claim Manager to lead and oversee the end-to-end medical claims process. This role ensures claims are handled efficiently, accurately, and in compliance with company policies and regulatory standards. The ideal candidate will collaborate with internal and external stakeholders to enhance customer satisfaction and maintain the integrity of the claims process.

Key Responsibilities:

• Claims Management: Supervise and ensure the smooth processing of medical claims, from submission to settlement, while maintaining service quality standards.
• Risk Assessment & Decision-Making: Analyze medical claims, assess risks, and provide expert judgment on claim approvals or rejections based on medical and insurance guidelines.
• Process Optimization: Lead initiatives to improve efficiency in claims processing, including automation and workflow enhancements.
• Regulatory Compliance: Ensure all claim assessments comply with industry regulations, internal policies, and ethical standards.
• Stakeholder Coordination: Work closely with medical providers, underwriters, and policyholders to resolve claim-related issues promptly.
• Team Leadership & Development: Manage, train, and mentor the claims team to maintain high performance and professional growth.
• Reporting & Analysis: Generate reports on claims trends, fraudulent activities, and cost management insights to support strategic decision-making.

Qualifications:

• Doctorate in Medicine (MD) is mandatory.
• Minimum 5 - 8 years of experience in medical claims management, underwriting, or a related field within the insurance industry.
• Strong knowledge of medical insurance policies, regulatory requirements, and claims adjudication processes.
• Excellent analytical and decision-making skills with attention to detail.
• Proven leadership experience in managing teams and optimizing operational efficiency.
• Effective communication and stakeholder management skills.
• Ability to work under pressure and handle complex claim cases with a solution-oriented mindset.