Manager - Technical Health Claims

Role Overview

This position leads the technical side of health insurance claims handling across the full journey from submission through adjudication. The role is designed to protect claim integrity before payment, ensure that claims follow policy terms, technical rules, contracts, system checks, and regulatory obligations, and improve the quality and efficiency of the overall claims operation.

Core Accountabilities

Operations

• Oversee the day-to-day work of the technical claims unit so health claims are processed accurately and on time.
• Make sure claims handling aligns with policy wording, provider agreements, internal procedures, regulatory expectations, and NPHIES requirements.
• Track operational performance indicators and resolve issues that affect output, quality, and service levels.
• Detect and stop invalid, non-compliant, or duplicate claims before adjudication and payment.

Data Analysis and Controls

• Review claims data to spot patterns, inconsistencies, and areas where performance can be improved.
• Build and maintain controls that support compliance with technical claims rules, policy conditions, contract terms, and regulations.
• Follow up on processing exceptions, system validation errors, and operational inconsistencies so claims are handled correctly and in line with requirements.

Process Improvement

• Identify opportunities to strengthen claims processes, improve submission quality, and reduce inefficiencies.
• Work with relevant stakeholders to improve system logic, automation, and validation controls.
• Use intelligent automation and digital tools to simplify workflows, reduce manual effort, and raise accuracy and speed.
• Support ongoing improvement initiatives that enhance operational effectiveness, accuracy, and productivity.

KPI and Compliance Management

• Ensure claims activities are completed within agreed KPIs while meeting technical and regulatory standards.
• Continuously review performance and identify ways to improve efficiency, quality, and compliance.

Qualifications

• A bachelor’s degree in business administration, healthcare administration, insurance, or a closely related discipline.
• Strong prior experience in health insurance claims operations, technical claims leadership, or a comparable role in insurance or healthcare.
• Good knowledge of the health insurance claims lifecycle, interpretation of policy terms, provider contracts, and technical claims guidelines.
• Experience with claims submission workflows, validation rules, and NPHIES transactions is strongly preferred.
• Solid ability to use Microsoft Office tools, especially Excel, PowerPoint, and Word, for analysis, reporting, and presentations.
• Experience with data analysis tools and AI-enabled solutions is an added advantage for improving operational decisions and efficiency.