Job Purpose
The Health Insurance Contract and Claims Manager will oversee the administration and management of insurance contracts, ensuring compliance with regulatory requirements and organizational policies. The role holder will also manage the claims process, ensuring timely and equitable resolution of claims, and providing expert guidance on insurance-related matters.
Core Responsibilities
Insurance Management
- Accurately interpret insurance policies to determine coverage, exclusions, and limitations and apply relevant policy provisions to specific claims and underwriting scenarios.
- Oversee the entire claims process, from initial notification to final settlement, investigate claims to determine liability, coverage, and potential losses.
- Negotiate settlements with claimants or their representatives, manage the claims handling process, including documentation, communication, and payment and identify and mitigate potential fraud and abuse.
- Monitor, assess and evaluate risks associated with insurance policies and claims and implement risk management strategies to minimize losses.
- Ensure compliance with all relevant insurance regulations, including licensing, reporting, and solvency requirements.
- Manage reinsurance programs, including treaty negotiations, placements, and claims recoveries and analyze reinsurance treaties to optimize coverage and minimize costs.
Claims Handling
- Receive and acknowledge insurance claims, investigate claims to determine coverage, liability, potential losses and collect and analyze relevant documentation, such as medical records, police reports, and property damage assessments.
- Assess the extent of damages and losses incurred by the insured, determine the appropriate coverage and policy limits, and calculate the estimated cost of repairs or replacements.
- Negotiate settlements with claimants or their representatives, process and authorize claim payments and ensure timely and accurate claim settlements.
- Identify and investigate potential fraud or abuse in insurance claims, collaborate with law enforcement and other relevant authorities as needed and implement measures to prevent and detect fraud.
- Communicate effectively with claimants, explaining the claims process and providing updates on the status of their claims.
Contract Negotiation
- Review and analyze insurance contracts, endorsements, and reinsurance treaties to ensure compliance with legal and regulatory requirements, identify potential risks and opportunities within contracts and develop strategies to mitigate risks and maximize benefits.
- Negotiate terms and conditions with clients, brokers, and reinsurers, balance the interests of the company with those of the counterparty and seek to optimize contract terms in terms of coverage, pricing, and conditions.
- Draft and finalize insurance contracts, endorsements, and other legal documents, ensure that contracts are clear, concise, legally enforceable, and obtain necessary approvals and signatures for contract execution.
- Monitor contract performance to ensure compliance with terms and conditions, address any contract disputes or claims and update contracts as needed to reflect changing circumstances.
- Manage relationships with vendors and suppliers, negotiate contracts with vendors and suppliers and monitor vendor performance and ensure compliance with contract terms.
Risk Assessment
- Identify potential risks to the insurance business, such as operational risks, financial risks, and reputational risks and assess the likelihood and potential impact of identified risks.
- Collaborate with other departments to identify and address risk exposures, implement risk management frameworks and policies to govern risk management activities and review risk management procedures to ensure their effectiveness.
- Manage the claims process, including investigation, assessment, and settlement. Identify and mitigate potential fraud and abuse in claims and implement effective claims management practices to minimize losses and expedite claim settlements.
- Develop and implement reinsurance programs to transfer risk and protect the financial stability, negotiate reinsurance treaties with reinsurers and monitor reinsurance recoveries and ensure timely payments.
- Stay updated on regulatory changes and industry best practices and ensure compliance with regulatory requirements, including solvency, capital adequacy, and reporting standards.