About the Company:
Cosmopolitan Health Insurance is a leading health insurance provider committed to delivering exceptional healthcare coverage and services to our members. We are dedicated to ensuring quality care, operational efficiency, and integrity in all our claims processes.
Job Summary:
We are seeking a detail-oriented and analytical Claims and Clinical Audit Officer to join our team. The successful candidate will be responsible for reviewing, verifying, and auditing medical claims to ensure accuracy, compliance with policy terms, and cost-effectiveness. This role requires a strong clinical background to assess medical necessity, detect fraudulent activities, and maintain high standards of healthcare service delivery.
Key Responsibilities:
- Review and process medical claims submitted by healthcare providers and members, ensuring they comply with company policies, tariff structures, and regulatory guidelines.
- Conduct clinical audits of medical records and billing to verify the appropriateness and medical necessity of treatments, procedures, and medications.
- Identify discrepancies, overbilling, unbundling, and potential fraudulent claims, and take appropriate action.
- Verify medical codes (ICD, CPT) and ensure they match the clinical documentation provided.
- Coordinate with healthcare providers and hospitals to resolve claim disputes and clarify medical information.
- Prepare detailed audit reports and highlight trends in claims utilization and provider billing practices.
- Ensure timely processing of claims to meet service level agreements (SLAs).
- Stay updated on medical advancements, insurance regulations, and industry best practices.
Qualifications and Experience:
- Bachelor’s degree in Nursing, Medicine, Pharmacy, Health Administration, or a related field.
- Must be a licensed/registered clinical professional (e.g., Registered Nurse, Physician Assistant, Pharmacist).
- Minimum of 2-3 years of proven experience in health insurance claims processing, clinical auditing, or a hospital/clinical setting.
- Strong knowledge of medical terminology, clinical procedures, and medical coding systems.
- Familiarity with health insurance operations, NHIS regulations, and private health insurance practices in Ghana.
- Excellent analytical, problem-solving, and decision-making skills.
- Proficient in Microsoft Office Suite (Excel, Word) and experience with claims management software.
- High level of integrity, attention to detail, and ability to work under pressure
Salary
Competitive
Monthly based
Location
Ghana
Ghana