Job Purpose
To evaluate Medical claims submitted to the company and determine whether claims meet eligibility standard of the company and ensure that the medical customers receive proper care and assistance before, during admissions and on discharge.
To reduce the cost of Care by managing all treatment and procedures with the doctors and medical service providers.
Responsibilities
Claims Processing
Review capturing of all the medical /surgical bills for reasonable and necessary charges from service providers.
Examine coding for operative reports procedures and multiple complicated surgeries and ensure correctness In charging
Verifying and auditing medical claims to ensure supporting documents are attached and returning invoices without proper documentation to the provider for completeness.
Evaluate claims submitted from service providers for reimbursement and make decisions regarding reasonableness of the payments.
Recommend appropriate payment of disputed billing as necessary.
Monitors service providers in view of ensuring they maintain high standards of service delivery to Pacis Insurance Customers
Negotiate payment rates with medical service providers.
Carry out periodic review of reserves for claims at specified time and providing a report for the same to supervisor.
Process and settle authorized medical claims to service providers and insured in a fair and timely manner in accordance with the set standards and credit limits/periods.
Ensures that reconciliation of medical statement is done timely and all disputes addressed
Prepares monthly claims reports for the management
Care Management
Pre-authorize scheduled and non-scheduled medical cases and timely issuance of letters of undertaking.
Review and maintain incurred claims amounts to a minimum by applying managed care tools, claims experience and analysis of benefits utilization patterns to ascertain the business viability.
Negotiation of the doctors’ bills and charges in view of reducing the cost of care before or during admissions
Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi
Provide second review of bills where providers question the appropriateness of payment authorized
Ensure customer queries and complaints are registered and follow through to finality
Resolve the customers queries and complains on time and advise them on details of the medical product
Recommends and Undertakes Health talks in liaison with the underwriters for all corporate medical schemes biannually.
Liaise with the intermediaries or corporate administrators and next of kin to the patients hospitalized as need arise.
Manages the Emergency calls in order to assist customers access medical care during office and off office ours
Facilitation of Admission , Discharges and Evacuation of Clients as per the company guidelines
Customer Service
Weekly running and sending out active members list to preferred panel of providers
Timely respond to clients queries, ,telephone call and letter regarding medical claims instituted to organization
Preparing and follow up on payment vouchers for service providers
Advising clients to utilize NHIF packages instead of spending on their insurance cover
Ensure adherence to contracts and service level agreements between providers and the company
Preparing and sending of the correct remittances to clients
Timely communication to clients about the status of their claims
Overseeing timely and accurate scanning of medical documents in Fortis
Any other duty assigned from time to time
Qualifications
Business Degree qualification is an added advantage
Diploma in Nursing/Clinical Officer
Skills and Attributes
Good Communication and interpersonal skills
Good analytical skills and keen on details
Excellent Negotiation skills
Effective decision maker
Experience
Three (3) years’ experience in medical insurance
Applications with a detailed CV, indicating the preferred location and telephone contacts with names and addresses of three referees should be emailed to hr@paciskenya.com not later than 15th February 2021.
Apply via :
hr@paciskenya.com
