Our client is a private hospital based in Nairobi and categorized as Level 4 by Kenya Medical Practitioners and dentist board.
They’re hiring for the role of Medical Claims Officer.
Salary: KES 48,000 – 63,000
This role reports to the Head of Clinical Services
Job Summary: To control and manage medical claims processes & procedures through the use of effective techniques to achieve the objectives of claims cost control, operational efficiency and meeting of the customer service charter in claims payment.
Duties and Responsibilities
- Responsibility for the administration of all insurance claims and associated queries
- Attend to escalated and complex medical claims to ensure these are attended to in a timely manner, and that they do not expose the business to any risk
- Develop processes for claims management to support efficiency and effectiveness Processing and Payment of claims to all providers in line with the standard service agreement as well as the contractual agreement therein
- Develop policies and procedures that guide the management of medical claims to ensure compliance with the specific client’s service level agreements as well as insurance regulations
- Ensuring claims are processed efficiently and correctly by working closely with insurers, claimants or their representatives, and relevant departments
- Risk Supervision – Overall process management to shield the company from any potential liability emanating from claims processing
- Ensuring complete and sound claim settlements, legal reviews and investigations in accordance with company policies and procedures
- Claims Review and Approval – Review claims processed to ensure that all claims fall within scope of respective medical insurance policy and comply with claims management policies and procedures.
- Business Advisory – Monitor and review claims trends and provide necessary advisory to the business for decision-making, innovation, and strategy review.
- Investigating potentially fraudulent claims
- Maintaining company records on claims and providing reports to senior management on a regular basis
- Generating own correspondence on contentious issues, providing updates and advice to senior management where required
- Liaising with colleagues to identify improvements in claims procedures
- Maintaining current knowledge with regard to industry compliance and claims regulation
- Providing professional advice to staff and senior management on all aspects of insurance practice and law
- Degree in Nursing or Clinical Medicine
- Professional qualification in Insurance (AIIK or ACII) will be an added advantage.
- Diploma in Insurance and or a degree in Health systems Management/ Business management will be an added advantage
- 7 years in health insurance operations 3 of which must be in a managerial role in a Hospital setting
Skill & Competencies
- 2 years’ experience in Hospital setting
- At least 3 years of experience working as a claims team leader in a busy Hospital environment
- 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 benefit utilization management.
- Integrity and honesty Knowledge of insurance industry and concepts
- Knowledge of insurance regulatory requirement
- Strong negotiation skills
- Creative & open-minded
- High level of numeracy and strong analytical skill
How to Apply
Interested candidates are requested to email their application letter and detailed CV with current and expected remuneration to email@example.com (note it’s .co and not .com) on or 20th October 2021.
Applications will be reviewed on a rolling basis.
Initial interview sessions will be done through Google Meet.