Claims Management Officer II (Dispatch Centre) - 22 Posts at The Social Health Authority (SHA)

Qualifications, Skills and Experience Required:

For appointment to the grade of Claims Management Officer II (SHA Grade 8), a candidate must meet the following entry requirements for degree holders in this cadre:

• Bachelor’s Degree in Medicine, Nursing, Clinical Medicine, Medicine and Surgery, or its equivalent qualification from a recognized institution.
• Membership to the relevant professional body (e.g., Nursing Council of Kenya, Clinical Officers Council, KMPDC) and in good standing.
• Proficiency in computer applications.

Responsibilities:

• The Claims Management Officer II (Dispatch Centre) serves as an entry and training grade officer responsible for ensuring that emergency medical dispatch cases and subsequent claims adhere strictly to established medical protocols, service charters, and SHA benefit packages, particularly those governed by the Emergency, Chronic, and Critical Illness Fund (ECCIF). This role focuses heavily on Quality Assurance (QA) and clinical compliance in the time-sensitive environment of the National Ambulance Dispatch Centre.

Key Responsibilities

• As an entry and training grade officer, the Claims Management Officer II (Dispatch Centre) works under the guidance of a senior officer and is typically deployed in Claims Management (Quality Assurance and Surveillance) functional areas.

Duties and responsibilities entail performing and assisting in the following:

• Monitoring and Review: Monitoring and reviewing medical-related customer interactions and claims initiated through the dispatch process.
• Quality Surveillance: Undertaking quality assurance surveillance in respect of claims to detect errors and inconsistencies at the dispatch level.
• Clinical Audits: Conducting clinical and service quality audits in line with SHA standards and medical protocols, and ensuring adherence to clinical protocols and service charters.
• Compliance Monitoring: Undertaking compliance monitoring and quality assurance activities related to emergency case handling.
• Claim Validation: Carrying out the reviewing, processing, and validating of medical claims from healthcare providers and facilities under supervision.
• Appraisal: Assisting in the appraisal of medical claims based on the benefit package (e.g., ECCIF) to determine eligibility and prevent misuse.
• Pre-Authorization: Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package while ensuring compliance with procedures.
• System Operation: Assisting in the operationalization of an e-claims management system to facilitate accurate and efficient claims processing within the Dispatch Centre.
• Fraud Control: Assisting in implementing systems and controls for detecting and identifying fraud appropriate to the Authority’s exposure and vulnerability.
• Sensitization: Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.
• Data Analysis: Collecting and analyzing data for purposes of claim management to enhance efficiency in claims processing.
• Report Generation: Developing detailed reports on compliance trends and recommending strategic interventions (e.g., preparing monthly medical quality reports with corrective recommendations).