Job purpose
The Claims Analyst handles the claims the platform cannot settle automatically: exceptions, disputes, and anything the fraud and anomaly rules flag for a human decision.
Key responsibilities
Adjudication
- Review and adjudicate exception claims that fall outside automated rules.
- Apply scheme benefit structures, limits, exclusions, and waiting periods correctly and consistently.
- Process pre-authorisation requests within agreed turnaround times.
- Escalate claims that require clinical or commercial sign-off.
Anomaly and dispute handling
- Investigate duplicate claims, tariff mismatches, and unusual provider billing patterns surfaced by the platform.
- Work with providers to correct documentation and reduce avoidable rework.
- Prepare and document dispute resolutions with a clear audit trail.
Reporting
- Track claims turnaround, rejection reasons, and leakage indicators.
- Flag recurring adjudication issues so the rules can be tuned rather than worked around.
Key performance indicators
- Claims turnaround within agreed SLA
- Adjudication accuracy on audit sample
- Reduction in avoidable claim rework
- Dispute resolution within agreed timelines
Qualifications and experience
- Bachelor's degree in Insurance, Health Systems Management, Nursing, or a related field.
- Minimum of 3 years' experience in medical claims adjudication with an insurer, TPA, or hospital.
- Working knowledge of benefit structures, tariffs, and pre-authorisation workflows.
- Comfortable working in claims management software and spreadsheets.
- Strong attention to detail and sound judgement under time pressure.
Competencies
- Leadership and people management
- Strategic thinking and execution
- Attention to detail
- Accountability and integrity
- Excellent organisational and coordination skills
- Customer-centric approach
- Continuous improvement mindset
