Responsible for ensuring claims processes and services meets the established standards to guarantee efficiency, monitor and prepare controls for managing claims cost
KEY PRIMARY RESPONSIBILITIES
Conduct an audit of overall claims settled, placing special attention to high value, repeated visits, and duplicate claims. Check the error rate.
Review of STP claims in line with acceptable process agreement
Identify Providers with significant billing irregularities or suspected of fraud and have regular provider engagement issues on billing.
Admissions tracking; checking on exaggerated bills, unnecessary admissions or overstay admissions, and doctors’ charges.
Enforce claims cost controls e.g. co-payments, discounts, provider restrictions, waiting periods
Frequent claimants, irregular services against MOH clinical standards of service
High average cost providers
Reimbursement reports review to pick exceptions and cold calling/impromptu visits.
Monitor and share reports of TATs for all key claims processes credit, reimbursement claims, discount claims.
Identify areas of improvement and scale up the STP process.
Business Related Degree
Risk / Quality assurance experience will be an added advantage
JOB SKILLS AND REQUIREMENTS
Team player with strong interpersonal and persuasive skills
Good Communication and interpersonal skills
Good analytical skills and keenness to details
Excellent Negotiation skills and Effective decision maker
Certificate of Insurance Proficiency or any Insurance-related qualifications
Quality Assurance professional qualification will be an added advantage
At least 3 years of relevant experience in a busy environment