Medical Claims Processor

Role overview

The Medical Claims Processor will be accountable for assessing and settling medical reimbursement claims in line with the policy wording, Table of Benefits (TOB), and standard operating procedures (SOPs). The position calls for consistent daily output, strong accuracy, and adherence to service-level commitments.

Claims adjudication and processing

• Evaluate and adjudicate claims correctly and within the required turnaround time, following the TOB and the applicable SOPs.
• Work in full alignment with the approved medical claims adjudication guidelines.
• Issue claim decisions only within the stated policy coverage and delegated authority.

Performance expectations

• Maintain 98% adjudication accuracy.
• Follow SOPs and medical protocols without deviation.
• Keep audit errors low and sustain strong quality scores after review.

Daily operations

• Handle all claims assigned by the Line Manager within a 10-calendar-day turnaround time.
• Meet the daily productivity standards set by management.
• Ensure each claim is completed end to end in line with regulatory requirements.

Additional responsibilities

• Escalate audit observations to the Line Manager and audit team, including any suspected fraud, wastage, abuse, or misuse.
• Share suggestions and feedback on system improvements that can increase efficiency and lower provider escalations.

Collaboration and working relationships

• Partner with internal teams such as Network, Approvals, and IT to quickly resolve claims-related issues.
• Contribute to a coordinated and efficient workflow across departments.

Qualifications and experience

Applicants should hold a bachelor’s degree in Medicine, Healthcare Management, Insurance, Nursing, Pharmacy, or a similar discipline. A minimum of 1 to 3 years of experience in medical claims processing or healthcare insurance is preferred, particularly in payer or TPA settings. Strong familiarity with medical insurance policies, TOB, and claims adjudication procedures is required. A certificate in healthcare coding practices such as ICD, CPT, or an equivalent framework is also necessary.

Additional information

• This is a one-year contract position.
• The compensation is positioned at an entry-level range.
• The selected candidate must be available to start immediately.