Claims Analyst at Old Mutual

Job Description

Job Summary

A Claims Analyst is responsible for accurately capturing claim details into the system, verifying documentation, ensuring policy compliance, and flagging inconsistencies to facilitate efficient claims processing and minimize errors.

Key Duties & Responsibilities

• Evaluate inpatient and outpatient medical claims for completeness and accuracy.
• Verify that claimed services are medically necessary, correctly coded, and fall within the policy scope.
• Ensure claims are captured within agreed turnaround times (TATs).
• Cross check claims against policy benefits, exclusions, and pre-authorizations.
• Maintain accurate claim records and documentation in the claims system.
• Generate daily, weekly, and monthly reports on claims trends, rejections, and approvals.
• • Flag and escalate abnormal utilization patterns or possible fraud cases.
• Work closely with underwriting, CXC, and finance departments.
• Accurately capture and update claim data in the claims management system.
• Ensure claims are categorized and archived appropriately for audit readiness.
• Maintain daily logs of claims captured per source/provider.
• Flag unusual or inconsistent data entries to the supervisor or vetting team.
• Participate in weekly performance reviews to track accuracy and productivity
• Update claim status after capturing (e.g., “Captured”, “Pending Vetting”, “Queried”).
• Correct any capturing errors as advised by clinical vetters or reconciliation teams.
• Index all claims and ensure physical and scanned copies are properly organized.
• Label and link supporting documents to each claim accurately for traceability.
• Support reconciliation and retrieval during audits.
• Confirm that claim documents (invoice, claim form, SHIF deduction, pre-authorization, discharge summary, etc.) are complete and properly attached.
• Verify member eligibility, policy status, and benefit limits based on system or cover summary.
• Check for duplication of claims or repeated submissions and flag them appropriately
• Enter claim data accurately into the claims processing system (inpatient, outpatient, maternity, dental, optical, etc.).
• Ensure all required fields (member details, provider details, ICD-10 codes, CPT codes, amounts, etc.) are correctly filled.
• Assign the correct claim type, benefit category, and service date.
• Process off smart claims and claims that failed to get pushed by smart through the lite link.
• Process cancelled claims: scheme reversals, wrong membership, wrong provider, wrong currency, wrong benefits.
• Linking of inpatient and optical claims.
• Any other duty as me be assigned from time to time.