Job Summary

The role holder will be responsible for processing of medical claims with a focus on accuracy, cost containment, risk management, and customer excellence.

Key Responsibilities

•  Review, assess, authenticate, and capture outpatient and inpatient claims as per the claims manual and within the set TATs
•  Timely scanning, barcoding, and batching of received claims
•  Processing of reimbursements within the set TATs
•  Conduct quality assurance process before batches are authorized for pay run
•  Notify brokers and clients of pended and declined claims within set timelines
•  Manage pended and declined claims
•  Liaise with agents, brokers, and service providers on matters arising from claims
•  Ensure all claims documents are archived in the relevant systems
•  Maintain claims production within set targets
•  Generate daily health claims status report
•  Storage of all correspondence in the Medware system
•  Monitoring and processing of NHIF-enhanced benefits for cost containment
•  Recording and monitoring of roaming and counter-guarantee claims.
•  Customer service – address clients’ queries in the form of telephone queries, letters, emails, and walk–in clients.
•  Maintain proper department standards, discipline, and confidentiality regarding patients’ illness.

Qualifications

• Bachelor’s degree/ Diploma in medical, Actuarial, insurance, or business-related discipline
• Progress towards a Diploma in Insurance will be an added advantage
• 6 months experience in medical claims, insurance/ hospital billing

Competencies

• Knowledge of insurance concepts
•  Knowledge of medical claims processes and procedures
•  Knowledge of insurance regulatory requirements
•  Stakeholder management
•  Customer service
•  Good Microsoft Excel skills and math aptitude
•  Delivering results and meeting customer expectations
•  Following instructions and procedures
•  Coping with pressures and setbacks
•  Analysing
•  Relating and networking
•  Presenting and communicating information
•  Working with people
•  Adhering to principles and values
•  Achieving personal work goals and objectives