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

Responsibilities:

Duties and responsibilities entail overseeing the implementation of actuarial assessment and benefit design policies, strategies, guidelines, and processes. The Director undertakes actuarial assessments to inform benefit packages and coordinates the implementation of internal control measures for sustainable insurance and medical schemes. This role also involves overseeing the implementation of appropriate rating guidelines for existing products, coordinating the preparation of periodic actuarial assessment and benefit design reports, and overseeing the identification, customization, and implementation of appropriate medical coding systems and health management information systems. The Director oversees the design and development of models for new benefits packages based on customer needs, reviews, processes, and validates medical claims from healthcare providers, and appraises medical claims based on the benefit package. Issuing pre-authorizations for healthcare services, developing an e-claims management system, undertaking quality assurance surveillance for claims, and establishing systems to detect and identify fraud are also key responsibilities. The Director sensitizes claimants on the consequences of submitting false claims, collects and analyzes data for claim management, prepares quarterly claims reports for submission to the Board and Cabinet Secretary, and manages contracted and outsourced claims management services.

Qualifications, Skills and Experience Required:

Person Specifications (Minimum Requirements): For appointment to this grade, a candidate must have:

• Cumulative service of fifteen (15) years of work experience, with five (5) of those years at a Senior Management level or in a comparable position.
• A Bachelor’s Degree in Medicine, Nursing, Clinical Medicine, Medicine and Surgery, Statistics, Mathematics, Health Financing, Health Economics, Pharmacy, Actuarial Sciences, Dentistry, or equivalent qualification from a recognized institution.
• A Master’s Degree in Medicine, Nursing, Medicine and Surgery, Business Administration, Public Health, Health System Management, Health Economics, Health Financing, Statistics, Mathematics, or equivalent qualification from a recognized institution.
• A valid practicing license where applicable from a recognized institution.
• Membership of a recognized professional body and in good standing.
• A Certificate in Leadership courses lasting for at least four (4) weeks from a recognized institution.
• Demonstrated managerial, administrative, and professional competence in work performance and results.