Job Summary: The Medical Board Consultant / Medical Approval Officer will primarily scrutinize in a professional manner medical claims (both reimbursement and direct billing) and to provide prior approval for medical treatment. In carrying out this role the jobholder will liaise and negotiate with the medical providers to ensure the validity of the treatment as per the insurance policy terms and conditions and to ensure that prices are in line with those agreed for Network providers or remain “reasonable and customary” for non Network providers. The role is responsible for effective communication with the Insured Members in order to explain the covers and answer any specific question related to a given claim.
Key Duties and Responsibilities:
The jobholder will manage all relations with the Medical Providers which includes negotiating all the discounts, studying all the price lists, handling reconciliations and visit the Medical Providers on a regular basis;
Analyse prior-approval requests, negotiate the cases with the medial providers, approve the cases when agreement is reached and enter the claim into AXA Insurance E.C. IT system;
Supervise In-patient claims (this supervision includes visits to the patients during their hospitalization);
Advise on Medical Basics and Practice;
Assist Medical Claims Administrators in processing claims;
Validate all medical claims in AXA Insurance E.C’s IT system;
Communicate with Insured Members on their claims and on any request coming from an Insured Member
Drive training and information seminars on AXA Insurance E.C. medical products directed toward clients, prospects and internal Sales forces.
Ensure that all medical information is kept confidential.
Qualifications, Skills and Experience:
The applicant should have completed Tertiary education in Medical degree (Medicine).
Three years of experience in related field.
Extensive knowledge of all medical insurance policies, billing policies and pricing / fee arrangements.
Expert knowledge of medical conditions, treatments and procedures in order to guide claimants and challenge medical practitioners and healthcare providers.
Basic understanding of competitors and their products.
AXA is a French multinational insurance firm headquartered in the 8th arrondissement of Paris that engages in global insurance, investment management, and other financial services. The AXA Group operates primarily in Western Europe, North America, the Asia Pacific region, and the Middle East, with presence also in Africa. AXA is a conglomerate of independently run businesses, operated according to the laws and regulations of many different countries.