BACKGROUND

Prime Insurance Ltd is an insurance company, established in 1995 and licensed by the National Bank of Rwanda (BNR) to offer general insurance services.

JOB PURPOSE

The Medical Claims Inspector is a critical operational role responsible for the accurate, efficient, and ethical assessment of medical insurance claims. This position ensures the validity of claims, mitigates fraudulent activity, and upholds policy terms to protect the company's financial integrity while delivering fair and timely service to policyholders and healthcare providers.

KEY RESPONSIBILITIES

Under the supervision of the Head of Medical, the Medical Claims Inspector shall have the following responsibilities:

Underwriting Support:

• Provide expert input to underwriting teams, helping to design risk acceptance requirements, develop underwriting guidelines, and assess potential risks associated with insuring certain individuals or groups.

Provider Network Management:

• Maintain relationships with clients, and healthcare providers, sometimes assessing the quality and compliance of facilities within the network through inspections.

Medical Claims Investigation & Adjudication:

• Support internal operations, primarily by evaluating the medical appropriateness of claims, managing risk, and ensuring compliance with regulations and best practices.
• Analyze medical reports, bills, prescriptions, and other supporting documentation to determine claim eligibility and appropriate benefit levels.
• Apply medical knowledge and policy terms to make precise adjudication decisions regarding approvals, modifications, or denials.

Fraud Detection & Risk Mitigation:

• Proactively identify potential indicators of fraudulent, exaggerated, or non-covered claims through detailed analysis and established protocols.
• Document findings thoroughly and escalate suspicious cases according to company procedures

Stakeholder Communication & Coordination:

• Liaise directly with policyholders, and third-party administrators to request information, clarify details, and communicate claim decisions.
• Provide clear explanations of benefits, coverage limitations, and claim outcomes to all relevant parties.
• Collaborate with internal teams, including Underwriting and Finance, to provide feedback on claim trends affecting risk and pricing.

Compliance & Process Management:

• Ensure all claims are processed in strict adherence to company policies, insurance regulations, and data protection laws.
• Ensure the company's adherence to clinical governance rules, advertising regulations, and other legal provisions by participating in internal audits and on-site inspections of various departments or external healthcare providers.
• Maintain accurate and detailed electronic claim files within the claims management system.
• Contribute to the development and refinement of claims assessment guidelines and procedures.

KEY DELIVERABLES

• Accurate and timely adjudication of medical claims within established service level agreements (SLAs).
• Effective detection and reporting of potentially fraudulent or erroneous claims, protecting company assets.
• Clear, professional, and compliant communication with all external stakeholders.
• Meticulously documented claim files that support all adjudication decisions.
• Positive outcomes in internal and external claim audits.

REQUIRED QUALIFICATIONS & EXPERIENCE

Experience:

• A minimum of Three years of experience in medical claims processing, health insurance administration, or a clinical/medical billing role. Experience in claims investigation or fraud detection is a strong advantage.

Education:

• Bachelor’s degree in Medicine. Possess a license to practice medicine and being recognized by the medical council. A Master’s in public health of related field is highly desirable.

Language:

• Fluency English, French and Kinyarwanda.

KEY COMPETENCIES

• Strong understanding of medical terminology, procedures, and billing codes.
• Excellent analytical, investigative, and attention-to-detail skills.
• High integrity and ethical standards with the ability to handle sensitive and confidential information.
• Effective communication and interpersonal skills for managing difficult conversations.
• Proficient in the use of claims management software and the Microsoft Office Suite, particularly Excel.
• Ability to work independently, manage a high-volume caseload, and make sound judgments.

WORKING RELATIONSHIPS

Internal:Claims Manager and team, Underwriting Department, Finance Department, Customer Service.

External:Policyholders, Hospitals & Healthcare Providers, Medical Laboratories, Third-Party Administrators (TPAs), Insurance Regulatory Body (RHIA)

• Provide expert input to underwriting teams, helping to design risk acceptance requirements, develop underwriting guidelines, and assess potential risks associated with insuring certain individuals or groups.
• Maintain relationships with clients, and healthcare providers, sometimes assessing the quality and compliance of facilities within the network through inspections.
• Support internal operations, primarily by evaluating the medical appropriateness of claims, managing risk, and ensuring compliance with regulations and best practices.
• Analyze medical reports, bills, prescriptions, and other supporting documentation to determine claim eligibility and appropriate benefit levels.
• Apply medical knowledge and policy terms to make precise adjudication decisions regarding approvals, modifications, or denials.
• Proactively identify potential indicators of fraudulent, exaggerated, or non-covered claims through detailed analysis and established protocols.
• Document findings thoroughly and escalate suspicious cases according to company procedures
• Liaise directly with policyholders, and third-party administrators to request information, clarify details, and communicate claim decisions.
• Provide clear explanations of benefits, coverage limitations, and claim outcomes to all relevant parties.
• Collaborate with internal teams, including Underwriting and Finance, to provide feedback on claim trends affecting risk and pricing.
• Ensure all claims are processed in strict adherence to company policies, insurance regulations, and data protection laws.
• Ensure the company's adherence to clinical governance rules, advertising regulations, and other legal provisions by participating in internal audits and on-site inspections of various departments or external healthcare providers.
• Maintain accurate and detailed electronic claim files within the claims management system.
• Contribute to the development and refinement of claims assessment guidelines and procedures.

• Strong understanding of medical terminology, procedures, and billing codes.
• Excellent analytical, investigative, and attention-to-detail skills.
• High integrity and ethical standards with the ability to handle sensitive and confidential information.
• Effective communication and interpersonal skills for managing difficult conversations.
• Proficient in the use of claims management software and the Microsoft Office Suite, particularly Excel.
• Ability to work independently, manage a high-volume caseload, and make sound judgments.

• Bachelor’s degree in Medicine.
• Possess a license to practice medicine and being recognized by the medical council.
• A Master’s in public health of related field is highly desirable.
• Fluency English, French and Kinyarwanda.