Sr. Officer – Claims Monitoring - TPA

Role Purpose:

To establish a full control on TPA’s providers' financial reconciliation and payments; playing a gate keeper role to ensure accuracy and avoid over / under payments to be made within agreed KPIs with stakeholders

Accountabilities:

Medical Providers Control (TPA)

• Prepare the provider’s financial reconciliation and perform a role of gatekeeper of payments and ensure to apply the accurate payments
• Reconcile the Providers accounts from different systems including Accpac, Caesar and our internal documents to make sure all figures are accurately recorded and track historical record of the providers’ monthly payments
• Monitor & ensure accuracy of provider payments documentation flow requests sent by claims; and ensure all required supporting documents are in place prior to payments
• Manage the recovery of over payments from providers to keep the payments log accurately

Provider’s Settlement (TPA)

• Generate the Commercial Financial Figures for Provider relations team as a baseline for decision making
• Ensure that prompt payment discounts and volume discounts are applied correctly
• Manage all of the negative Full & Final settlement and supervise the process of collecting the negative provider settlements amounts in order to secure accurate settlements for our accounts
• Resolve and reconcile provider’s yearly opening balances by Mid-year and coordinate with the Provider relations and claims department in order to settle the provider’s accounts in an efficient way

Provider Analysis

• Prepare the weekly NBS by monitoring the variance between projected and actual costs through the batches received versus projections and make enhancements as required
• Fully understand the TPA models to be a backup for the manager while also providing insight on the cost trends and analysis

Regulatory & External Audit

• Assist in ensuring that the reporting system and provider payments are well supported by documents and policies & procedures to support the TPA audit

Years of Experience 

• 0-2 years of experience

Skills Required (Technical)

• Strong MS office skills.
• Analytical and reporting skills with a good understanding of the business drivers.

Other Requirements

• BSC Degree in Finance, Accounting
• Strong commuincation skills
• Process and results orianted, with strong attention to details