Assistant Manager – Claims Vetting at CIC Insurance

PURPOSE:

Responsible for supervision of claims vetting and audit to ensure all claims paid are according to the company policy and guidelines.

PRIMARY RESPONSIBILITIES:

• Coordinate and ensure cost containments measures/targets set within the claims vetting section are achieved.
• Ensure claims vetting and audit daily output targets are achieved and overall levels are maintained within acceptable ranges.
• Prepare weekly and Monthly reports on claims output, individual and group cost savings, rejections and exclusions.
• Ensure candidates for wellness and Chronic Disease management are flagged at claims vetting section based on clinical trends for follow-up by the wellness coordinator.
• Coordinate with claims registration and provider relations department to ensure payments to providers have been settled within the acceptable timelines as per SLAs.
• Responsible for communication of inadmissible reimbursement claims on clinical matters to the key stakeholders.
• Coordinate with provider management team and claims registration section to ensure desired provider reconciliations and sign offs are achieved.
• Provide appropriate recommendations on provider trends to clinical operations team and management for appropriate action.
• Monitor claims trends to identify high cost providers and together with provider relations team engage providers to ensure desires trends are achieved.;
• Recommend risk improvement measures for implementation to the underwriting department by monitoring claims experience trends
• Resolve customer complaints and disputes swiftly, fairly and diplomatically that concerns claims vetting section.

GENERIC DUTIES

• Carry out performance appraisal, coaching and mentoring staff;
• Participate in planning and budgeting for the department.

PERSON SPECIFICATIONS

Academic Qualifications

• Bachelor’s degree in nursing, business or other related fields
• Registered nurse or clinical Medicine

Professional Qualifications

• Kenya Registered Nursing (KRN) diploma
• IIK/CII preferred

Experience

• Minimum of four (5) years’ relevant experience

Skills and Attributes

• Excellent communication and presentation skills
• Problem solving skills
• Excellent interpersonal skills
• Good analytical skills
• Computer literate in MS Office and other office applications
• Understanding of the working environment /competitors
• Technical competence in insurance
• Basic knowledge of regulations by AKI and IRA