Claims Analyst, Retail Health

Job Summary

• The role holder will be responsible for assisting in risk management through assessing the eligibility of applicants to obtain medical cover, scheme performance analysis, proposal of appropriate renewal terms and scheme administration for those already on medical cover within the set standards of service

Key Responsibilities

• Review, assess, authenticate and capture outpatient and inpatient claims as per the claims manual and within the set TATs
• Timely scanning, barcoding and batching of received claims
• Processing of reimbursements within the set TATs
• Conduct quality assurance process before batches are authorized for pay run
• Notify brokers and clients of pended and declined claims within set timelines
• Manage pended and declined claims
• Liaise with agents, brokers and service providers on matters arising on claims
• Ensure all claims documents are archived in the relevant systems
• Maintain claims production within set targets
• Generate daily health claims status report
• Storage of all correspondence in Medware system
• Monitoring and processing of NHIF enhanced benefits for cost containment
• Recording and monitoring of roaming and counter-guarantee claims.
• Customer service – address clients’ queries in form of telephone queries, letters, emails and walk –in clients.
• Maintain proper department standards, discipline and confidentiality regarding patients’ illness.
• Embrace governance requirements with respect to KYC/AML/Data protection requirements per governing Acts.

Qualifications

• Bachelor’s degree in Insurance or business-related discipline
• Progress towards Diploma in Insurance (ACII or AIIK), (at least 3 papers or equivalent)

Experience

• 1 years’ experience in medical claims management in insurance/hospital setting

Competencies

• Understanding of insurance operations and concepts
• Knowledge of insurance regulatory requirements
• Knowledge of claims procedures
• Excellent organizational and stakeholder management skills