PURPOSE:
Responsible for supervision of claims vetting and audit to ensure all claims paid are according to the company policy and guidelines.
PRIMARY RESPONSIBILITIES:
Coordinate and ensure cost containments measures/targets set within the claims vetting section are achieved.
Ensure claims vetting and audit daily output targets are achieved and overall levels are maintained within acceptable ranges.
Prepare weekly and Monthly reports on claims output, individual and group cost savings, rejections and exclusions.
Ensure candidates for wellness and Chronic Disease management are flagged at claims vetting section based on clinical trends for follow-up by the wellness coordinator.
Coordinate with claims registration and provider relations department to ensure payments to providers have been settled within the acceptable timelines as per SLAs.
Responsible for communication of inadmissible reimbursement claims on clinical matters to the key stakeholders.
Coordinate with provider management team and claims registration section to ensure desired provider reconciliations and sign offs are achieved.
Provide appropriate recommendations on provider trends to clinical operations team and management for appropriate action.
Monitor claims trends to identify high cost providers and together with provider relations team engage providers to ensure desires trends are achieved.;
Recommend risk improvement measures for implementation to the underwriting department by monitoring claims experience trends
Resolve customer complaints and disputes swiftly, fairly and diplomatically that concerns claims vetting section.
GENERIC DUTIES
Carry out performance appraisal, coaching and mentoring staff;
Participate in planning and budgeting for the department.
PERSON SPECIFICATIONS
Academic Qualifications
Bachelor’s degree in nursing, business or other related fields
Registered nurse or clinical Medicine
Professional Qualifications
Kenya Registered Nursing (KRN) diploma
IIK/CII preferred
Experience
Minimum of four (5) years’ relevant experience
Skills and Attributes
Excellent communication and presentation skills
Problem solving skills
Excellent interpersonal skills
Good analytical skills
Computer literate in MS Office and other office applications
Understanding of the working environment /competitors
Technical competence in insurance
Basic knowledge of regulations by AKI and IRA
Apply via :
cic.co.ke
