Deputy Director, Claims Management at The Social Health Authority (SHA)

Qualifications, Skills and Experience Required:

• Fifteen (15) years of cumulative service period of work experience, with at least three (3) years at Assistant Director, Claims Management Officer or comparable.
• Bachelor’s Degree in Medicine and Surgery from a recognized institution (for Medical Review). 
• Master’s Degree in Medicine and Surgery from a recognized institution (for Medical Review).
• A valid practicing license from a recognized institution.
• Certificate in Leadership course lasting not less than four (4) weeks from a recognized institution.
• Proficiency in computer applications.
• Demonstrated managerial, administrative, and professional competence in work performance and results.

Responsibilities:

Job Purpose: 

• This cadre is responsible for ensuring that claims are processed and cases are managed efficiently and effectively.

Functions: 

• Coordinating medical reviews and interpretation of medical reports.
• Overseeing the reviewing, processing, and validating of medical claims from healthcare providers and healthcare facilities to ensure accuracy and adherence to policies.
• Coordinating the appraisal of medical claims based on the benefit package to ensure fair and timely disbursement of funds.
• Overseeing the issuance of pre-authorizations for access to healthcare services based on the benefit package while ensuring efficiency in service delivery.
• Ensuring assessment of quality health care providers for purposes of declaration.
• Ensuring enforcement and compliance with contractual provisions by healthcare providers.
• Spearheading the development and operationalization of an e-claims management system for improved claims processing and fraud detection.
• Coordinating the undertaking of quality assurance surveillance in respect of claims to identify gaps and recommend corrective actions.
• Establishing systems and controls for detecting and identifying fraud appropriate to the Authority’s exposure and vulnerability to minimize financial risks.
• Facilitating sensitization of claimants on the consequences of submitting false and fraudulent claims to enhance compliance and transparency.
• Coordinating the collection and analysis of data for purposes of claim management to inform strategic decisions and policy formulation.
• Supervising the preparation of quarterly reports on claims for submission to the Board and the Cabinet Secretary to ensure timely reporting and accountability.
• Carrying out any other functions as necessary for the better execution of the Authority’s mandate under the Act.
• Coordinating the management of contracted and outsourced claims management services to enhance efficiency and service delivery.