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Managing the health claims to ensure prompt and fair settlement of all medical claims in accordance with the claims guidelines in order to control claims expenditure and maintain good working relationship with service providers.
KEY TASKS AND RESPONSIBILITIES
- Leading the claims team and ensuring claims processing is executed within the scheme rules and defined procedures and rates,
- Oversee processing & settlement of service providers, reimbursement and subsidiary claims within stipulated TATs
- Ensure provider monthly payment expectations are met
- Review and authorization of payment runs.
- Coordination of provider reconciliations with the finance team and service providers.
- Review of provider reconciliation statement for verification of UAP liability, payment and sign off statement of account.
- Oversee vetting of claims both inpatient and outpatient including vetting of claims above 1M as per approval matrix level
- Develop and maintain service provider panels by holding regular business meetings with key service providers.
- Participate in provider rationalization committee meetings.
- Resolve difficult client enquiries, ensure timely completion of investigations/resolution arising from claims disputes in claims teams.
- Staff administration – Supervise, training and mentor staff on technical matters.
- Prepare regular claims reports to management and advice underwriter health on relevant claims findings for medical risk review.
- Systems Enhancement-Continuously review the effectiveness of workflow systems and recommend enhancement
- Support implementation of the EDI claims platform and/or any other initiatives by the company
- Quality Assurance- Perform regular quality checks on the claims process and take appropriate corrective action
SKILLS AND COMPETENCIES
- Excellent communication and negotiation skills.
- Excellent public relations and interpersonal relationship skills.
- Extensive networking with SP and other medical insurers
- Excellent analytical and monitoring skills
- User IT skills in database management and office systems.
- Ability to evaluate decisions made in health management.
- Ability to work long hours, under pressure from service providers especially due to payment issues
- Ability to handle emotional clients
- Integrity and honesty
- People management
- Analytical and reporting skills
- Relationship management skills
EDUCATION, KNOWLEDGE & EXPERIENCE
- Degree in relevant medical field e.g Clinical officer, nursing, pharmacy
- Diploma in clinical medicine, surgery and community medicine
- Professional insurance certificates/ diplomas/ advanced diploma
- 3 years’ experience in insurance industry
- Process management
- Insurance industry market awareness
08 October 2021