Claims Management Officer II - 2 Posts at The Social Health Authority (SHA)

Qualifications, Skills and Experience Required:

For appointment to this grade, a candidate must have: 

• Bachelor’s Degree in Medicine, Nursing, Clinical Medicine, Medicine and Surgery or its equivalent from a recognized institution; 
• Membership to the relevant professional body and in good standing; and 
• Proficiency in computer applications. 

Responsibilities:

You will be responsible for reviewing, processing, and validating medical claims, appraising claims based on benefit packages, issuing pre-authorizations, and undertaking quality assurance surveillance.

Officers in this cadre may be deployed to any of the following functional areas:- 

• Claims Management 
• Claims Management (Quality Assurance and Surveillance) 

Claims Management 

Key responsibilities

• Carrying out the reviewing, processing, and validating of medical claims from healthcare providers and healthcare facilities under supervision; 
• Assisting in the appraisal of medical claims based on the benefit package to determine eligibility and prevent misuse; 
• Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package while ensuring compliance with procedures; 
• Assisting in the operationalization of an e-claims management system to facilitate accurate and efficient claims processing; 
• Collecting and analyzing data for purposes of claim management to enhance efficiency in claims processing; and 
• Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities. 

Quality Assurance and Surveillance 

Key responsibilities

• Undertaking quality assurance surveillance in respect of claims to detect errors and inconsistencies; 
• Assisting in implementing systems and controls for detecting and identifying fraud appropriate to the Authority’s exposure and vulnerability; 
• Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities; 
• Undertaking compliance monitoring and quality assurance activities in assigned regions. 
• Supervise clinical audits and develop corrective action plans for non-compliance. 
• Coordinating the implementation of Hospital Quality Improvement Teams (HQITs); 
• Monitoring benefit utilization and accessibility trends within the region; and 
• Developing detailed reports on compliance trends and recommend strategic interventions.