Key Responsibilities:

• Oversee the claims process flows to ensure efficiency in processing of claims as per the company medical claims procedure manuals.
• Supervise processing and settlement of medical claims as per the claims manual and customer service charter to ensure compliance and mitigate risk
• Holding regular business meetings with service providers to ensure compliance with stipulated claims procedures and other contractual terms.
• Monitor, prevent and control medical claims fraud by carrying out regular audits on the internal and external systems and processes, as well as service providers.
• Claims cost management through enforcement of agreed tariffs, negotiation of preferential rates and discounts, monitoring claims trends and conducting utilization review.
• Reviewing of the outstanding claims regularly and monitoring team adherence to claims payments Turn Around Time (TAT).
• Oversee the business document management process to ensure prompt scanning of claims documents and indexing in the relevant systems.
• Supervise, train and mentor medical claims and operations staff to achieve a high level of motivation and productivity.
• Prepare regular claims and operations reports to management, intermediaries and clients and advice underwriting team on relevant claims findings for medical risk review.
• Working directly with finance team in management of service provider reconciliations, processing & release of payments.
• Maintaining strong working relationships with service providers, Intermediaries, Clients, all departments and all business stakeholders
• Work closely with ICT and Business analysts for any decision making on implementation of system requirements for claims cost management.
• Complying with statutory, regulatory and internal control processes at the business units including internal & external audits recommendations.
• Entrenching performance-based appraisal of departmental staff in line with their set KPI’s and departmental targets.
• Any other roles assigned by management from time to time

Requirements

Skills and Competencies Required

• Strong leadership and management skills
• Ability to work independently and build effective interpersonal relations
• Bias towards innovation and development of new ideas in problem solving
• Professionalism in dealing with both internal and external stakeholders
• Excellent communication and negotiation skills.
• Extensive networking with service providers and other medical insurers
• Excellent analytical and monitoring skills
• Ability to evaluate decisions made in benefit utilization management
• Integrity and honesty

Knowledge & Experience

• Demonstrated knowledge of managed care practices, medical claims management and business operations.
• At least 3 years’ managerial experience in a medical insurance environment
• Addressing operational concerns and issues, monitoring overall customer satisfaction.
• Demonstrated experience engaging service providers at high level, and experience negotiating claims handling terms with providers
• Developing and implementing operational procedures and policies

Academic and Professional Qualifications required

• Degree in medicine/pharmacy/nursing or Business-Related field
• ACII or DIP AIIK or CIM qualifications
• Master’s Degree is an added advantage