Jobs at Old Mutual Kenya

Key Tasks And Responsibilities

Audit of settled claims;

• Conduct audit of overall claims settled, placing special attention to high value, repeated visits, and duplicate claims. Check error rate.
• Identify Providers with significant billing irregularities or suspected of fraud and have regular provider engagements issues on billing.
• At the end stage of provider reconciliation, claims that relate to benefit excesses are to be reviewed and liability assigned to either UAP, client / scheme or Smart.
• Admissions tracking; checking on exaggerated bills, unnecessary admissions or overstay admissions, doctors’ charges.
• Review integration exception report between E02 and d365.
• Review system rejections of claims.

Conduct trending analysis; identify leakage; and prepare objective reports on claims and case processing processes

• Enforce claims cost controls e.g. copayments, discounts, provider restrictions, waiting periods
• Monitor and ensure compliance to SOPs for claims, case and provider management
• Manage reserve philosophy for admission/ approval and enhanced amounts. Review IP bills for scheduled cases monthly.
• Reimbursement reports review to pick exceptions and cold calling/impromptu visit.

Contribute to the development of process-specific, competency-based trainings;

• Identify knowledge gaps and training needs of the claims, case team
• Identify gaps in policy terms and review together with the retention team.
• From the findings of the audit of IP and OP settled claims, give recommendations and remedial actions. And drive implementation of said actions

Prepare reports to communicate outcomes of quality activities

• Monitor and share reports of TATs for all key claims processes
• Track claims paid in E02 vs D365; use of the exception reports to monitor paid, reversed and cancelled claims

monitor risk management activities: GIA issues

• Prepare regular claims reports to management and advice underwriter health on relevant claims findings for medical risk review.
• Root cause and close out

Systems Enhancement

• Continuously review the effectiveness of workflow systems and recommend enhancement.

Resolve difficult client enquiries:

• ensure timely completion of investigations/resolution arising from claims disputes in case management and claims teams.
• Investigate suspected fraud issues; guide the fraud reporting to GFS and follow up to closure.
• coach, counsel or train less-experienced staff; provide input in the performance management, goal setting and review processes.

Skills And Competencies

• Decision Making,
• Continuous Renewal,
• Client Focus,
• Information Monitoring,
• Gaining Commitment
• Team Orientation
• Initiating Action
• Analytical skills

Knowledge & Experience

• Technical Knowledge
• At least 3 years’ experience

Qualifications

• Degree in a medical related field
• Medical background
• Professional license
• Experience in claims processing and vetting
• Quality assurance experience will be an added advantage

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Job Description

KEY TASKS AND RESPONSIBILITIES

• Enforce underwriting controls
• Ensure compliance with underwriting guidelines
• Debiting of premiums and processing of policy documents within set timelines
• Debiting and processing of renewal endorsements
• Processing and checking of underwriting Documents
• Issuing of Endorsements
• Issuing of Motor Certificates
• Issuing and signing of yellow cards
• Review and dispatch of notices within set TAT
• Ensure work is done within the set standards of service – Customer service charter
• Do a detailed weekly mail reports on outstanding work.
• Give quality customer service to all our clients.
• Safe keeping yellow cards.
• Daily scanning and indexing of mails
• Issuance of valuation letters and follow up
• Adherence to the credit control policy
• Follow up renewals and reporting on status
• Processing of client and Bank refunds
• 100% Adherence to the authority matrix
• Adherence to the underwriting guidelines and memos
• Ensure registry is fully maintained in an orderly and is up to date
• Ensure compliance of AML and PEP guidelines
• Ensure cross sale and up sale opportunities are maximized.
• Premium receipting of Mpesa, VISA and cheque payments and ensure cheques are banked on time -GI and Medical
• Issuing customers with updated/ correct customer statements
• Assisting clients with claims reporting (both GI & Health) and follow ups with Head office
• Onboarding of retail medical clients and ensuring the customers receive medical cards
• Perform any other duties as may be required by the management.

Skills And Competencies

• Basic Underwriting skills
• Customer service skills
• Good Communication Skills
• Computer Literate

Qualifications, Knowledge & Experience

• Business Related Degree
• Advanced Industry Qualifications/ C.O.P
• 1 year’s experience preferably in the Insurance Industry