Reporting to the health care Administrator-Bancassurance, the role holder will be responsible for day-to-day engagement with medical providers to ensure quality healthcare provision to members of medical schemes, processing of claims as per the company medical claims procedure and manual.

Key Responsibilities

• Process claims: Verify and analyzing medical claims as per scheme scope of cover whilst ensuring strict adherence to set guidelines and timelines.
• Manage Costs: Negotiate rates and discounts and monitor trends
• Reconcile claims: Ensure claims are paid on time and reconcile with estimates
• Follow up on claims: Ensure claims are reimbursed on time, and follow up on outstanding claims
• Maintain records: keep records of claims related documents and payment vouchers and provide information to finance department
• Reports: preparation of utilization reports and other reports as required by member / client
• Communicate with providers: Resolve issues, clarify billing and share information
• Claim cost: management through enforcement of agreed tariffs, monitoring claims trend and conducting utilization review
• Compliance – Ensure legal compliance of medical claims data in accordance with the Data Protection Act and any other legislative guidelines.
• Relationship: Maintain strong working relationship with service providers, Insurance company partners, customers and business stakeholders

The Person

For the above position, the successful applicant should have the following:

• Bachelor’s degree in healthcare related field.
• Professional Qualification in COP will be an added advantage
• A master’s degree in health management or business will be an added advantage
• At least 1 year in claim processing
• At least 1 year claim vetting.
• At least 1 year Provider account reconciliations