JOB PURPOSE
Collaborate with medical clients, intermediaries, and medical service providers to facilitate access to quality, timely, effective, and cost-efficient healthcare services with the aim of achieving business growth, profitability, and customer retention.
PRINCIPAL ACCOUNTABILITIES
Claims Processing:
Confirmation of membership, validity, and benefits before processing claims.
Capture and vet medical bills within the client's benefit
structure and as per negotiated customary, reasonable rates.
Correctly reserve inpatient bills on discharge and approved outpatient cases.
Preparing and sending the correct reimbursement remittances to clients.
Communicating any claim dispute or rejection to the clients and intermediaries.
Case Management and Customer Service:
Receive and respond to medical emergency lines and ensure 24-hour coverage.
Issuance of both inpatient and outpatient approvals for admissible requests for insured members.
Communication and notification to stakeholders on management of cases, discharges, admissions, and financial liability
Coordinate with the clients and medical providers to leverage on SHA rebates and packages.
Negotiation of hospital and doctors' charges with the aim of optimal cost containment before or during admissions.
Weekly running and sending out active members list to preferred panel of providers.
Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi.
Resolve all customer queries immediately and promptly escalate complex cases
Send weekly and monthly reports on admissions, exceptional claims, long stay, savings, claims production amongst others.
Qualifications:
Minimum Academic Qualification:
Bachelor's degree Nursing/ Diploma in Nursing /Clinical Medicine
Professional Qualifications
Nursing Council of Kenya
AIIK or Certificate of Proficiency -Insurance
Experience:
One year's experience in health insurance