Case and Claims Manager at CarePay Ltd

MAIN PURPOSE OF THE JOB:

• The Case and Claims Manager will have the responsibility to drive and grow and the case and claims management strategy; oversee the processing of health insurance claims to ensure the procedure is handled efficiently, accurately, and enhance the quality of patient management, maximize satisfaction, and promote cost effectiveness. The successful candidate will be accounting for the full patient care cycle in a manner that protects the interests of all parties while also providing satisfactory customer service.

KEY DUTIES AND RESPONSIBILITIES:

Case Management:

• Set up relevant reporting tools and dashboards related to In-Patient case management.
• Coordinating care that is safe, timely, effective, efficient, equitable, and client centered.
• Scale further the inpatient and outpatient patient policies and procedures.
• Identify areas of cost saving and putting up infrastructures that eliminate fraud.
• Coordinating and attending member visits under inpatient based on set parameters.
• Take the lead within the team to champion addressing root cause issues that impact Healthcare provider and member NPS (Net Promotor Score).
• Lead the design and implementation of innovative, cost-effective pricing agreements (e.g., price packages) for IP treatments (incl. optimizing NHIF (National Hospital Insurance Fund) refund structures)

Claims Management:

• Manage and handle all claims in accordance with set payer standards and internal procedures and any local regulations.
• Have measures in place to mitigate and Manage claim risks by having a standardized verification and auditing process in place of both in-patient and out-patient claims ensuring these are in line with Policy requirements, our claims manual, our customer service charter whilst ensuring compliance to data privacy and other applicable regulations.
• Oversee processing, settlement of all claims and reimbursements.
• Management of timely response of pre-authorizations.
• Holding regular business meetings with healthcare providers to ensure compliance with contract terms, use of agreed systems and agreed prices.
• Monitor, prevent and control medical claims fraud by carrying out regular audits on the internal and external systems.
• Prepare regular claims reports to clients on key performance metrics and provide regular trend analysis.
• Scale further claims automation.

Team Management:

• Monthly formal feedback and coaching sessions with direct reports.
• Supervise, train and mentor medical case and claims staff to achieve set targets, achieve high level of motivation and productivity by the team.
• Contributing to the team’s success by partnering with others to review operating procedures and processes, ensuring that the best possible service is maintained, and the ultimate customer experience is provided.
• Organize appropriate learning sessions to build experience and enhance the expertise within the team.
• Manage and build the relationship with external consultants that may be supporting the team.

EDUCATIONAL QUALIFICATIONS, KNOWLEDGE & EXPERIENCE:

• University degree in Medicine or Pharmacy (Masters is an added advantage).
• ACII or its Equivalent.
• Current license, certification, or registration.
• At least 5 years’ experience in a busy hospital set-up.

KEY SKILLS AND COMPETENCIES:

• Good understanding of private and public healthcare delivery.
• Have a strong understanding of medical treatment protocols and cost-effective prescribing habits in relation to market segmentation.
• Extensive networking with healthcare providers and other medical insurers.
• Experience in managing a team.
• Excellent analytical and monitoring skills
• Excellent communication and negotiation & leadership skills.
• Excellent public relations and interpersonal relationship skills.
• User IT (Information Technology) skills in database management and office systems.
• Ability to evaluate decisions made in benefit utilization management.
• Integrity and honesty
• Ability to maintain confidentiality and patient confidentiality & Privacy.
• Personal qualities of integrity, credibility, professionalism, and a commitment to CarePay's mission.

Physical Demands and Working Hours:  

• Willingness to work weekends and/or night shift.