Medical Claims Analyst
Job description.
Reporting to Head – Benefits, the role holder
will be responsible for engagement with medical providers & insurance for
case management of the medical scheme, engage with medical service providers to
interrogate the nature and costing of medical services rendered to members
before claims processing, engaging with insurance underwriters on addition and
deletion of members as well as reconciliation with credit control teams of the
various providers in the panel as well as effective and efficient
administration of staff medical claims submitted for reimbursement.
The Role
Specifically, the successful jobholder will
be required to:
- Validate authenticity and
completeness of the information and attachments on all medical claims
presented by staff members for reimbursement whilst ensuring strict
adherence to set guidelines and TAT.
- Review all medical/surgical
billings for reasonable and necessary charges as well as evaluate claims
referred for medical management and make recommendations for follow-up,
further investigation or documentation as necessary and also vet and
analyse medical claims as per scope of cover whilst ensuring strict
adherence to set guidelines and TAT
- Correctly read and assess medical
documents to either approve or deny payment of medical claims and
accurately approve the e-payment files.
- Maintain accurate medical records,
preparation of informative management claims reports, administer the bank
funded Out-patient medical scheme and update staff medical statements and
ensuring all utilizations are captured on a timely basis.
- Ensure reconciliation of medical
providers’ bills & accounts on an ongoing basis or on demand including
visits to providers; recommend appropriate payment of dispute of billing,
as necessary.
- Ensure timely admission of new
staff and dependants to in & out-patient medical schemes and prepare
utilization reports as required by member / client.
- Provide professional assistance
to all the staff members/dependents with chronic ailments and facilitating
follow up in specialists’ clinics.
- Arrange for emergency evacuations
for medical scheme members’ country wide.
- Be the point of contact for staff
members and other stakeholders on health matters/issues as well as ensure
that staff members are educated especially on lifestyle issues and also
provide staff training and member education on quality health care cost
containment and utilization.
- Attends mediations and other
hearings to inform and defend the cost containment procedures, guidelines
and decisions rendered.
Skills, Competencies and Experience
The successful candidate will be required to
have the following skills and competencies:
- A Bachelor’s degree in a
medical/Health related field i.e. Nursing/ Clinical Medicine/ Pharmacy/
Medical Laboratory etc.
- At least 3 years’ experience in a
busy Health Insurance environment with Claims Vetting & Care
management. Experience in insurance and health sector is an added
advantage.
- Knowledge of Fraud Risks
associated with medical claims and experience in Medical reconciliation.
- Computer literate and familiar
with standard office software applications.
- Team player with strong
communication, interpersonal and persuasive skills with a strong ability
to build and maintain strong working relationships with a wide range of
internal and external stakeholders.
- Attentive to detail, good
planning and organization skills with the ability to deliver effectively
under strict deadlines. Maintains confidentiality and integrity of all
information in their possession.
How to Apply
If you believe you fit the job profile, please
email your application enclosing detailed Curriculum Vitae to jobs@co-opbank.co.ke indicating
the job reference number MCA/HRAD/2023 by Tuesday 9th May, 2023.
