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Claims Analyst, Health Business
Job Summary
The role holder will be responsible for processing of medical claims with a focus on accuracy, cost containment, risk management and customer excellence.
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.
Qualifications
- Bachelor’s degree/ Diploma in medical, Actuarial, insurance or business-related discipline
- Progress towards Diploma in Insurance will be an added advantage
Experience
- 6 months experience in medical claims, insurance/ hospital billing
Competencies
- Knowledge of insurance concepts
- Knowledge of medical claims processes and procedures
- Knowledge of insurance regulatory requirements
- Stakeholder management
- Customer service
- Good Microsoft Excel skills and math aptitude
- Delivering results and meeting customer expectations
- Following instructions and procedures
- Coping with pressures and setbacks
- Analysing
- Relating and networking
- Presenting and communicating information
- Working with people
- Adhering to principles and values
- Achieving personal work goals and objectives
Analyst, Care Management
Job Summary
The role holder will be responsible for ensuring that Heritage customers receive a ordable, accessible, cost e ective and high-quality healthcare services.
Key Responsibilities
- Maintain constant contact with hospitals to ensure continuous well-being of all the stakeholders and handling of medical claims with effciency and accuracy.
- Pre-authorise scheduled and non-scheduled admissions within the set guidelines
- Liaise with the hospitals and doctors for prompt discharge plan of the admiited members.
- Assess and authenticate inpatient and outpatient medical claim documents
- Ensure smooth discharge process and co-ordinate any necessary post-hospitalisation care
- Prescreening and vetting of inpatient, outpatient and reimbursements claims to ensure adherence to agreed tariffs and clinical protocols, with clear documented notes in case of decline and any discount offered by thecproviders
- Conduct hospital visits and monitoring of inpatient bills
- Daily monitoring of interim bills & appropriate interventions for high quality of care.
- Daily status reporting of the clinical status of the admitted members.
- Contact centre management, pre-authorization approvals on payments and responding to member and provider enquiries
- Ensure timely notification to the stakeholder team of all the declined cases as per the policy guidelines.
- Timely resolution of all the complaints raised by clients
- Responding to all clients and providers requests within 24 hours
- Ensure all counter guaranteed and roaming cases have offcial letters before approvals are done.
- Authorization of maternity bookings and wellness letters are issued within 24hrs.
- Monitoring client with chronic diseases by ensuring managed health care forms are completed by the doctors for proper follow up and management.
- Health talks, wellness and check-ups management with providers and all stake holders
- Ensure inculcation of the TCF (Treating Customers Fairly) culture
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Qualifications
- Degree or Diploma in Medicine, Nursing, Clinical Medicine or Pharmacy
- Progress towards Diploma in Insurance will be an added advantage
Experience
- 1 year experience in a healthcare setting
Method of Application
If you meet the above requirements, you are encouraged to forward your application and updated CV to vacancies@heritage.co.ke by 22nd October, 2023. Clearly state the job title on the subject heading