Specifically, the successful jobholder will be required to:
- Validate authenticity and completeness of the information and attachments on all medical claims presented by staff members for reimbursement whilst ensuring strict adherence to set guidelines and TAT.
- Review all medical/surgical billings for reasonable and necessary charges as well as evaluate claims referred for medical management and make recommendations for follow-up, further investigation or documentation as necessary and also vet and analyse medical claims as per scope of cover whilst ensuring strict adherence to set guidelines and TAT
- Correctly read and assess medical documents to either approve or deny payment of medical claims and accurately approve the e-payment files.
- Maintain accurate medical records, preparation of informative management claims reports, administer the bank funded Out-patient medical scheme and update staff medical statements and ensuring all utilizations are captured on a timely basis.
- Ensure reconciliation of medical providers’ bills & accounts on an ongoing basis or on demand including visits to providers; recommend appropriate payment of dispute of billing, as necessary.
- Ensure timely admission of new staff and dependants to in & out-patient medical schemes and prepare utilization reports as required by member / client.
- Provide professional assistance to all the staff members/dependents with chronic ailments and facilitating follow up in specialists’ clinics.
- Arrange for emergency evacuations for medical scheme members’ country wide.
- Be the point of contact for staff members and other stakeholders on health matters/issues as well as ensure that staff members are educated especially on lifestyle issues and also provide staff training and member education on quality health care cost containment and utilization.
- Attends mediations and other hearings to inform and defend the cost containment procedures, guidelines and decisions rendered.
The successful candidate will be required to have the following skills and competencies:
- A Bachelor’s degree in a medical/Health related field i.e. Nursing/ Clinical Medicine/ Pharmacy/ Medical Laboratory etc.
- At least 3 years’ experience in a busy Health Insurance environment with Claims Vetting & Care management. Experience in insurance and health sector is an added advantage
- Knowledge of Fraud Risks associated with medical claims with training in Basic and Advance Life Support.
- Computer literate and familiar with standard office software applications.
- Team player with strong communication, interpersonal and persuasive skills with a strong ability to build and maintain strong working relationships with a wide range of internal and external stakeholders.
- Attentive to detail, good planning and organization skills with the ability to deliver effectively under strict deadlines.
- Maintains confidentiality and integrity of all information in their possession.
If you believe you ﬁt the job proﬁle, please email your application enclosing detailed Curriculum Vitae to firstname.lastname@example.org indicating the job reference number MCA/HRD/2016 by Monday 20th June, 2016.