Medical Case Management/Claims Analyst at PACIS Insurance

MAIN DUTIES AND RESPONSIBILITIES

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.
• Process reimbursement documents and communicate to clients about the status of their claims.

Care Management

• Receive and respond to Medical emergency lines and ensure 24 hour coverage.
• 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 to ensure quality of care and cost containment. Post discharge follow up of patients to ensure adherence to care.
• Send weekly and monthly report on admissions, exceptional claims, long stay, savings amongst others.

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.
• 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

Academic Qualification

• Bachelor’s degree in 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