Manager - Technical Health Claims

The Technical Claims Manager is responsible for overseeing the technical management of health insurance claims throughout the submission and adjudication lifecycle. The role ensures compliance with policy provisions, technical guidelines, contractual agreements, system controls, and regulatory requirements, while safeguarding the integrity of claims prior to payment. The position focuses on optimizing claims submission quality, enhancing provider compliance, ensuring adherence to NPHIES standards, and driving continuous improvement in claims processes and operational efficiency.

Key Accountabilities

Operations:

▪ Manage the daily operations of the Technical Claims function, ensuring efficient and timely processing of health insurance claims.

▪ Ensure compliance with policy provisions, provider agreements, internal policies, regulatory requirements, and NPHIES standards.

▪ Monitor operational performance by tracking key metrics and addressing issues that impact productivity, quality, and service levels.

▪ Ensure the identification and prevention of invalid, non-compliant, or duplicate claims prior to adjudication and payment.

Data Analysis & Control:

▪ Monitor and analyze claims data to identify trends, discrepancies, and opportunities for improvement.

▪ Develop and maintain controls to ensure compliance with technical claims rules, policy provisions, contractual agreements, and regulatory requirements.

▪ Ensure effective monitoring and resolution of claims processing exceptions, system validation failures, and operational inconsistencies to ensure compliant and accurate claims processing.

Process Improvements:

▪ Identify and drive opportunities to enhance claims processes, improve submission quality, and reduce operational inefficiencies.

▪ Collaborate with relevant stakeholders to optimize system rules, automation, and validation controls.

▪ Leverage intelligent automation (IA) and digital solutions to streamline claims workflows, reduce manual interventions, and improve processing accuracy and efficiency.

▪ Support continuous improvement initiatives to enhance claims processing efficiency, accuracy, and operational performance.

KPI Management and Compliance:

▪ Ensure all claims processing activities are completed within established KPIs while maintaining full compliance with technical and regulatory requirements.

▪ Continuously monitor operational performance and identify opportunities to improve efficiency, quality, and compliance.

QUALIFICATIONS:

• Bachelor's degree in business administration, Healthcare Administration, Insurance, or a related field.
• ▪ Proven experience in health insurance claims operations, technical claims management, or similar function within insurance or healthcare environment.
• ▪ Strong understanding of health insurance claims lifecycle, policy interpretation, provider contracts, and technical claims rules.
• ▪ Experience in claims submission processes, validation rules, and NPHIES transactions is highly preferred.
• ▪ Strong proficiency in Microsoft Office applications (Excel, PowerPoint, Word) for reporting, analysis, and presentations.
• ▪ Exposure to data analysis tools and AI-driven solutions to enhance operational efficiency and decision-making is an advantage.