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