Senior Claims Management Officer - 96 Posts at The Social Health Authority (SHA)

Qualifications, Skills and Experience Required:

Person Specifications: Promotional-Claims Management-Medical Review:

• Cumulative service period of three (3) years’ work experience at the grade of Claims Management Officer I or in a comparable position.
• Bachelor’s Degree in Medicine and Surgery from a recognized institution.
• A valid practicing license.
• Membership to the relevant professional body and in good standing.
• Proficiency in computer applications.
• Shown merit and ability as reflected in work performance and results.

Promotional-Claims Management:

• Cumulative period of services of six (6) years’ work experience, three (3) of which should have been at the grade of Claims Management Officer I or in a comparable position.
• Bachelor’s Degree in Medicine, Nursing, Clinical Medicine, Medicine, and Surgery or from a recognized institution.
• Membership of a recognized professional body and in good standing.
• Proficiency in computer applications.
• Shown merit and ability as reflected in work performance and results.

Responsibilities:

Job Description: Officers in this cadre may be deployed to any of the following functional areas: Claims Management (Medical Review), Claims Management, County Coordination (Quality Assurance and Surveillance).

Claims Management (Medical Review):

• Carrying out the medical reviews of medical reports.
• 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.
• Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.

Claims Management:

• Undertaking reviewing, and processing, of medical claims from healthcare providers and healthcare facilities to ensure accuracy and compliance.
• Undertaking the appraisal of medical claims based on the benefit package to determine eligibility and prevent misuse of funds.
• Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package to facilitate timely service provision.
• Collecting and analyzing data for the e-claims and case management system to enhance efficiency and accountability.
• Conducting quality assurance surveillance in respect of claims to ensure adherence to policies and detect irregularities.
• Carrying out sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.
• Collecting and analyzing data for purposes of claim management to facilitate informed decision-making and continuous process improvement.
• Collating and analyzing of data for preparation of quarterly reports on claims for submission for transparency and accountability.
• Ensuring compliance with contractual obligations contracted and outsourced claims management services.

County Coordination (Quality Assurance and Surveillance):

• Conducting quality assurance surveillance in respect of claims to ensure adherence to policies and detect irregularities.
• Support the monitoring of compliance with SHI Act, policies, and procedures at the branch level.
• Implement operational standards and procedures to ensure efficient service delivery.
• Enforcing compliance with contractual provisions by healthcare providers.
• Collaborating in assessments of healthcare providers for empanelment.
• Support the preparation and maintenance of updated records for empaneled healthcare facilities.
• Collect and compile data for compliance monitoring and benefit utilization.
• Assisting in establishing systems and controls for detecting and identifying fraud appropriate to the Authority’s exposure and vulnerability.
• Carrying out sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.
• Collecting and analyzing data for purposes of claim management to facilitate informed decision-making and continuous process improvement.
• Ensuring compliance with contractual obligations contracted and outsourced claims management services.