Health Claims Associate

The Health Claims Associate supports the day-to-day processing of health insurance claims, ensuring accuracy, fairness, and compliance with company policies and procedures. The role focuses on managing straightforward claims efficiently, escalating complex or unusual cases to senior colleagues as needed.

KEY DUTIES AND RESPONSIBILITIES INCLUDE:

Insurance Product Knowledge

· Apply a good understanding of health insurance products, benefits, and exclusions to assess claims.

· Verify coverage and eligibility details before processing claims.

· Escalate any unclear or complex policy interpretations to senior team members.

Foundational Medical Knowledge

· Use basic knowledge of medical terminology and procedures to review and process claims accurately.

· Check that treatments and diagnoses align with policy coverage and required documentation.

· Escalate unclear or complex medical documentation for further review.

Claims Handling

· Process standard health insurance claims from start to settlement within defined authority limits.

· Ensure all documentation and information are complete before approving or rejecting claims.

· Identify and report discrepancies, delays, or potential errors promptly.

· Maintain regular communication with clients, healthcare providers, and intermediaries when additional information is needed.

Risk Assessment

· Follow company policies, regulatory guidelines, and data protection standards in all claims handling activities.

· Flag potential anomalies, high-value, or suspicious claims to senior team members.

· Maintain accurate records of all claims decisions and communications in the system.

Digital Proficiency

· Use the company’s claims management system to input, track, and update claim details.

· Ensure data accuracy and completeness to support reporting and audits.

· Support digital record-keeping and filing of all related correspondence.

Financial Processing

· Prepare payment requests for approved claims within delegated limits.

· Assist with verifying invoices and treatment costs.

· Escalate any discrepancies or unusual transactions to senior team members.

QUALIFICATIONS

· 1–2 years’ experience in health insurance, customer service, or a related administrative role.

· Basic understanding of insurance policies and claims processing procedures.

· Good command of English and Maltese; other languages are an asset.

· Computer literate, with experience using MS Office and claims management systems.

PERSONAL ATTRIBUTES

· Strong attention to detail and accuracy.

· Customer-oriented, with professional communication skills.

· Organised, efficient, and able to handle multiple tasks.

· Willing to learn and follow guidance from senior colleagues.

· Collaborative and dependable team player.