Job Purpose:

Reporting to the Claims Manager, the incumbent will be responsible for customer satisfaction by increased personal contact with clients in hospital and reduce turnaround time in processing of medical claims and enhance cost effective care of medical claims.

Key responsibilities:

• Posting reimbursements and provider invoice details into the Mashinani System.
• Maintain close contact with appointed health care service providers to ensure strict compliance with agreed procedures and guidelines.
• Ensure that healthcare providers have adequate claim forms to serve members.
• Carry out vetting and verification of outpatient and inpatient claims.
• Ensure that the panel of doctors is strictly adhered to by clients and hospitals in order to reduce claims costs.
• Enlisting providers on panel.
• Approval of emails and pre-authorisations within 24 hours for scheduled requests and promptly for emergency approvals.
• Assess medical claims documents for authenticity and process payments within set service levels.
• Maintain accurate records on medical claims.
• Manning of the 24hr helpline.
• Delegated Authority: As per the approved Delegated Authority Matrix

Key Performance Measures:

• Prompt response to emails and approvals.
• Prompt response to emergency line calls.
• Cost savings through proper vetting of claims.
• Timely processing of claims within set targets
• Promote customer satisfaction and retention.

Requirements

Knowledge, experience and qualifications required

• Bachelor’s degree in Nursing or Clinical Medicine.
• Proficiency in computer / software packages e.g. Microsoft word and Excel.
• Strong inter-personal skills and ability to work in a team-oriented and collaborative environment.
• Confident, articulate and with strong communication skills.

Technical/ Functional competencies:

• Knowledge of insurance products.