Assistant Director, Claims and Case Management - 2 Posts at The Social Health Authority (SHA)

QUALIFICATIONS

• Twelve (12) years cumulative work experience, three (3) of which should have been at the level of a Principal Officer or in a comparable position in the public or private sector;
• Bachelor’s degree in medicine and surgery, from a recognized institution
• Master’s degree in a relevant field from a recognized institution is an added advantage;
• Management course lasting not less than four (4) weeks at a recognized institution.
• Proficiency in computer applications.
• Membership to a professional body where applicable and in good standing; 
• Demonstrated merit and ability as reflected in work performance and results.
• Demonstrate a clear understanding of the SHI Act, 2023, and other laws relevant to SHA operations.
• Fulfill the requirements of Chapter Six of the Constitution.

Key Competencies and Skills

• Strong analytical skills
• Communication skills
• Strong interpersonal skills
• Negotiation skills

Responsibilities:​​​​​​​

• Participate in strategic and operational planning for claims management, defining the Health Care Benefits including health needs assessment, risk assessments and monitoring progress against strategic objectives;
• Formulate and implement policies and strategies for effective and efficient clinical management;
• Reviewing, processing and validating medical claims from healthcare providers and healthcare facilities;
• Oversee Issuing of pre-authorizations for access to healthcare services based on the benefit package;
• Appraising medical claims based on the benefit package;
• Coordinate quality assurance surveillance and claims adjudication in respect of claims;
• Establishing systems and controls for detecting and identifying fraud appropriate to the Fund’s exposure and vulnerability in collaboration with other departments
• Oversee Sensitization of claimants on the consequences of submitting false and fraudulent claims;
• Coordinate collecting and analysing data for purposes of claim management in collaboration with other departments. 
• Participate in collaborations with relevant entities in the Health Needs Assessment for clinical interventions and other technologies;
• Oversee preparation of reports on claims.
• Effective implementation and continuous improvement of Claims management information systems, ensuring they support efficient operations and member satisfaction in collaboration with the relevant entities in collaboration with other departments. 
• Establish and refine robust internal claims management controls to safeguard the sustainability, affordability, and integrity of benefits packages for all stakeholders. 
• Ensure compliance with local and international standards in Claims Management (as prescribed in the Act), fostering alignment with globally recognized best practices and enhancing the Authority’s reputation.
• Ensure the development and execution of policies and strategies for business process re-engineering, driving innovation and efficiency in Claims Management.
• Provide expert guidance in Claims management on reviewing and amending the Social Health Insurance Act, ensuring responsiveness to the evolving healthcare landscape and adherence to quality standards.
• Provide effective team leadership by setting clear expectations, fostering collaboration, resolving conflicts and maintaining a high performing team