Purpose of the job 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 clients benefit structure.Code, verify, audit and process medical claims within negotiated, customary and reasonable price.Correctly reserve bills on discharge and approved outpatient cases.Provide second review of bills where providers question the appropriateness of payment authorized. Care Management Review pre-authorization of admission, discharges, scheduled and emergency medical cases, issue timely responses as per policy benefits and company guidelines.Review of patient’s history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.Coordinate local and international emergency evacuations, referrals, and transfersSet the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.Negotiation of doctors’ and hospital bills and charges in view of reducing the cost of care before or during admissions.Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi. Post discharge follow up of patients to ensure adherence to care.Follow up care of admitted patients with the doctors and providers to ensure quality care and cost containment.Implement preventive care program through health talks, wellness and the chronic disease management program CDMP.Send weekly and monthly report on admissions, exceptional claims, long stay, savings amongst others.Audit service provider applications, process contracts and provider feedback Customer Service Oversee weekly sending out active members list to the providers.Update intermediaries and/ or scheme administrators on clinical, coverage and bills of admitted clients.Provide feedback and update to intermediaries and schemes on requested providers.Coordinate with the clients and medical providers to leverage on NHIF.Ensure adherence to contracts and service level agreements between providers and the company.Process reimbursement documents and communicate to clients about the status of their claims.Register, follow through and resolve the customers and provider queries and complains in time and advise them on outcome and the details of the medical product. Knowledge and experienceQualifications:Academic Qualification Bachelor’s degree Nursing/ Diploma in Nursing Professional Qualifications Nursing Council of KenyaAIIK Experience: Four years’ experience in health insurance Knowledge Understanding of insurance industry Skills & competencies Excellent communication and Interpersonal Skills.Problem SolvingEmpathyDecision MakingNegotiation SkillsEthicalTeam PlayerKeen to detailPlanning & Organization SkillsCustomer OrientedStakeholder managementDependability How To ApplyApplications with a detailed CV, indicating your telephone contacts with names and addresses of three referees should be emailed to email@example.com not later than Thursday 9th March 2023.N.B: 1.Dont Miss Out On Your Next Job. Let's Have Your CV. . NB: 2. Advance & Grow In Your Career?. Check Out Best short Courses For You.
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