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Job Description

The Health Insurance QA Officer is responsible for ensuring the accuracy and compliance of
health insurance claims processing within the organization. This role involves reviewing claims,
identifying errors or issues, and implementing corrective actions to improve quality assurance
processes.

KEY TASKS AND RESPONSIBILITIES

Quality Audits Of Claims.

Identify Providers with significant billing irregularities or suspected of fraud and have regular provider engagement issues on billing.Review claims that relate to benefit excesses, assign liability, and recover while ensuring the root cause is addressed.Admissions tracking; checking on exaggerated bills, unnecessary admissions or overstay admissions, and doctors’ charges.Review system rejections of claims for root causing and resolution.Quality audits on the vetters and ML module to identify quality gaps and remediate them.Identify and investigate any errors, discrepancies, or quality issues in the claims processing procedureCollaborate with various departments (e.g. underwriting, provider relations, IT) to resolve complex claims issues

Reporting and Trend Analysis.

Prepare objective reports on processes that lead to leakages and proposed mitigative measures.Review claims, and provide recommendations to claims, retention, case, and provider relations teams on trends noted: both from users and providers.Make recommendations to management regarding developing policies, processes, and procedures; identify and implement processing efficiencies; identify trends and continuing education opportunities.Manage reserve philosophy for admission/approved and or enhanced amounts through weekly audits to ensure the acceptable threshold is being met.Review reimbursement reports to pick exceptions and cold calling/impromptu visits to validate.Conduct regular process audits to enforce adherence to laid out SOPs across the health businessMaintain proper documentation of call performance and associated corrective measures as applicable

Training and Feedback

Designing effective training programs and collaborating with trainers to ensure the feedback loop from the QA audits is complete.Identify knowledge gaps and training needs of the relevant teams and hold calibration sessions and breakout training sessions as needed.Develop and implement quality control measures to prevent future errors and improve efficiencyStay up-to-date with changes in healthcare laws, regulations, and best practices related to claims management.Prepare regular claims reports to management and advise on relevant claims findings for medical risk review.Ensure all audit items are closed in your respective area.

Systems Enhancement

Continuously review the effectiveness of workflow systems and recommend enhancements.Provide input on ML and core system enhancements to improve quality and output.

Any other tasks/duty as may be assigned by the Line manager.

    

SKILLS AND COMPETENCIES

Aligns Execution - Planning and prioritizing work to meet commitments aligned with organizational goals.Proficiency with claims management software and data analysis toolsMotivated team player who is detail-oriented.Excellent communication skills, both written and verbalStrong working knowledge of the Microsoft suite of productsStrong analytical, problem-solving and decision-making abilities.

KNOWLEDGE & EXPERIENCE

3+ years experience in Quality Assurance/Medical claims/Case management In-depth knowledge of healthcare operations, claims processing, and regulatory requirements.Experience working in the Insurance industry preferred.Knowledge in data analysis and statistics are desirable.

QUALIFICATIONS

Bachelor's degree in Healthcare Administration, Nursing, Statistics Clinical Medicine or a related field

ANTI-MONEY LAUNDERING (AML) EXPECTATION

The incumbent will be responsible for ensuring adherence to, implementation of, and adoption of Compliance, Anti-Money Laundering (AML), and Sanctions-related policies, procedures, and process requirements within Old Mutual and its subsidiaries. This includes executing customer due diligence processes, ensuring compliance with Know-Your-Customer (KYC) standards, conducting ongoing and enhanced due diligence, and maintaining data quality. Additionally, the role involves identifying and monitoring potential AML, Sanctions, or Compliance breaches and unusual activities, and escalating these concerns to the Risk and Compliance Office for further action.

Skills

Competencies

Education

Closing Date

12 August 2025 , 23:59

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