PACIS Insurance Company – Medical Claims Analyst.

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PACIS Insurance Company Limited was incorporated in Kenya in October 2004 and is an initiative of the Catholic Church, with a vision to be the icon of reliability and trustworthiness.  

In order to serve our growing client base, the company wishes to recruit an experienced, dynamic and innovative Medical Claims Analyst in our Medical Department.

Job Purpose

To evaluate Medical claims submitted to the company and determine whether claims meet eligibility standard of the company and ensure that the medical customers receive proper care and assistance before, during admissions and on discharge.

To reduce the cost of Care by managing all treatment and procedures with the doctors and medical service providers.

Responsibilities

Claims Processing

  • Review capturing of all the medical /surgical bills for reasonable and necessary charges from service providers.
  • Examine coding for operative reports procedures and multiple complicated surgeries and ensure correctness In charging
  • Verifying and auditing   medical claims to ensure supporting documents   are attached and returning invoices without proper documentation to the provider for completeness.
  • Evaluate claims submitted from service providers for reimbursement and make decisions regarding reasonableness of the payments.
  • Recommend appropriate payment of disputed billing as necessary.
  • Monitors service providers in view of ensuring they maintain high standards of service delivery to Pacis Insurance Customers
  • Negotiate payment rates with medical service providers.
  • Carry out periodic review of reserves for claims at specified time and providing a report for the same to supervisor.
  • Process and settle authorized medical claims to service providers and insured in a fair and timely manner in accordance with the set standards and credit limits/periods.
  • Ensures that reconciliation of medical statement is done timely and all disputes addressed
  • Prepares monthly claims reports for the management 

Care Management

  • Pre-authorize scheduled and non-scheduled medical cases and timely issuance of letters of undertaking.
  • Review and maintain incurred claims amounts to a minimum by applying managed care tools, claims experience and analysis of benefits utilization patterns to ascertain the business viability.
  • Negotiation of the doctors’ bills and charges in view of reducing the cost of care before or during admissions
  • Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi
  • Provide second review of bills where providers question the appropriateness of payment authorized
  • Ensure customer queries and complaints are registered and follow through to finality
  • Resolve the customers queries and complains on time and advise them on details of the medical product
  • Recommends and Undertakes Health talks in liaison with the underwriters for all corporate medical schemes biannually.
  • Liaise with the intermediaries or corporate administrators and next of kin to the patients hospitalized as need arise.
  • Manages the Emergency calls in order to assist customers access medical care during office and off office ours
  • Facilitation of Admission , Discharges and Evacuation of Clients as per the company guidelines

Customer Service

  • Weekly running and sending out active members list to preferred panel  of providers
  • Timely respond to clients queries, ,telephone call and letter regarding medical claims instituted to organization
  • Preparing and follow up on payment vouchers for service providers
  • Advising clients to utilize NHIF packages instead of spending on their insurance cover
  • Ensure adherence  to contracts and service level agreements between providers and the company
  • Preparing and sending of the correct remittances to clients
  • Timely communication to clients about the status of their claims
  • Overseeing timely and accurate scanning of medical documents in Fortis
  • Any other duty assigned from time to time

Qualifications

  • Business Degree qualification is an added advantage
  • Diploma in Nursing/Clinical Officer

Skills and Attributes

  • Good Communication and interpersonal skills
  • Good analytical skills and keen on details
  • Excellent Negotiation skills
  • Effective decision maker

Experience

  • Three (3) years’ experience in medical insurance

How to Apply

Applications with a detailed CV, indicating the preferred location and telephone contacts with names and addresses of three referees should be emailed to hr@paciskenya.com  not later than 15th February 2021.

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