* Examine insurance claims, medical claims, or other types of claims submitted by customers or policyholders.* Verify the accuracy and completeness of claim documentation, including policy information, medical records, and supporting documents.* Evaluate claims in accordance with the terms and conditions of the insurance policy or relevant regulations.* Ensure that the claims processing complies with industry regulations, company policies, and legal requirements.* Investigate claims to determine their validity, which may involve interviewing claimants, witnesses, or healthcare providers.* Analyze data and information to make informed decisions regarding the acceptance or denial of claims.* Make claim adjudication decisions, including approving, denying, or adjusting claims.* Maintain detailed records of claim decisions, actions taken, and reasons for decisions.* Communicate with policyholders, claimants, and other stakeholders to provide updates on claim status, request additional information, or explain claim decisions.* Engage in negotiation with claimants, if necessary, to reach a settlement or resolve disputes.* Process approved claims for payment and ensure timely disbursement of funds.* Identify and investigate potentially fraudulent claims and take appropriate actions to prevent fraud.* Provide excellent customer service by addressing claimants’ inquiries and concerns professionally and efficiently.* Generate reports on claim adjudication activities, such as claims status, performance metrics, and trends.* Take up calls with stakeholders to address their issue relating to payments.* Handling member queries over email.* Participate in ongoing training and development to stay up to date with industry changes and improve claim adjudication processes.

Generate reports on claim adjudication activities such as claim status performance metrics