Case Manager/Claims Analyst at PACIS Insurance

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 transfers
• Set 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 EXPERIENCE

Qualifications:

Academic Qualification

• Bachelor’s degree Nursing/ Diploma in Nursing

Professional Qualifications

• Nursing Council of Kenya
• AIIK

Experience:

• Four years’ experience in health insurance

Knowledge

• Understanding of insurance industry

SKILLS AND COMPETENCIES

• Excellent communication and Interpersonal Skills.
• Problem Solving
• Empathy
• Decision Making
• Negotiation Skills
• Ethical
• Team Player
• Keen to detail
• Planning & Organization Skills
• Customer Oriented
• Stakeholder management
• Dependability