Claims Doctor

As a Claims Doctor at EFU Life Assurance Ltd., you play a pivotal role in the evaluation of medical claims to ensure accurate and fair assessment of insurance requests. Your medical knowledge and expertise in claims evaluation are essential in reviewing patient records, diagnostic reports, and treatment history. With an emphasis on detail and accuracy, you apply diagnostic skills to identify and assess the validity of claims related to various health issues. Strong communication skills enable you to articulate complex medical information clearly to both internal teams and clients, fostering transparency and trust. You will independently analyze medical documentation and data, ensuring all claims adhere to established medical criteria while maintaining compliance with industry regulations. Your role demands proficiency in medical coding, particularly ICD-10 coding, as you accurately categorize diagnoses and procedures to facilitate efficient processing of claims. You examine healthcare documentation thoroughly to determine the appropriateness of claims and identify any discrepancies. You do not manage a team in this role, allowing you to focus on your individual contributions and expertise in medical claims assessment, closely partnering with relevant stakeholders to enhance the claims process and improve client satisfaction.
Responsibilities

Review medical claims submissions to verify accuracy, completeness, and compliance with medical guidelines and policies.
Assess medical records, diagnostic reports, and treatment plans to evaluate the validity of each claim.
Utilize strong attention to detail to identify discrepancies or errors in claims documentation.
Apply ICD-10 coding principles to categorize medical diagnoses and procedures accurately.
Collaborate with claims processing teams to address inquiries and provide expert recommendations on complex cases.
Communicate findings effectively to internal stakeholders and clients, simplifying complex medical terminology.
Analyze data relating to claims submissions to identify trends and areas for improvement.
Ensure adherence to relevant regulations and standards within the healthcare and insurance sectors.
Provide feedback on process improvements to enhance efficiency in claims evaluation and processing.
Maintain up-to-date knowledge of changes in healthcare policies, medical practices, and coding systems to improve claims assessment.