Medical Claims and Operations Manager at Old Mutual Kenya

Job Description

The job holder will oversee the medical claims and operations units to ensure streamlined claims management, efficient business processing, claims cost control, operational efficiency, control environment and meeting customer service charter in claims payment and business processing.

KEY TASKS AND RESPONSIBILITIES

• Oversee the claims process flows to ensure efficiency in processing of claims as per the company medical claims procedure manuals
• Supervise processing and settlement of medical claims as per the claims manual and customer service charter to ensure compliance and mitigate risk
• Holding regular business meetings with service providers to ensure compliance with stipulated claims procedures and other contractual terms
• Monitor, prevent and control medical claims fraud by carrying out regular audits on the internal and external systems and processes, as well as service providers
• Claims cost management through enforcement of agreed tariffs, negotiation of preferential rates and discounts, monitoring claims trends and conducting utilization review
• Oversee the Business Processing and Retail Underwriting to ensure prompt booking of business, accurate membership management and timely processing of membership documents
• Oversee the business document management process to ensure prompt scanning of claims and underwriting documents and indexing in the relevant systems
• Oversee the Quality Assurance function within the health business
• Supervise, train and mentor medical claims and operations staff to achieve a high level of motivation and productivity
• Prepare regular claims and operations reports to management, intermediaries and clients and advice underwriting team on relevant claims findings for medical risk review
• Working directly with finance team in management of provider reconciliations and payments
• Direct oversight of the claim’s workflow (processing and settlement) to ensure efficiency in processing of claims as per the company medical claims procedure manuals
• Maintaining strong working relationships with service providers, Intermediaries, Clients, all departments and all business stakeholders
• Work closely with ICT and Business analysts for any decision making on implementation of system requirements.
• Any other roles assigned by management from time to time

SKILLS AND COMPETENCIES

• Strong leadership and management skills
• Ability to work independently and build effective interpersonal relations
• Bias towards innovation and development of new ideas in problem solving
• Professionalism in dealing with both internal and external stakeholders
• Excellent communication and negotiation skills.
• Extensive networking with service providers and other medical insurers
• Excellent analytical and monitoring skills
• Ability to evaluate decisions made in benefit utilization management
• Integrity and honesty

KNOWLEDGE & EXPERIENCE

• Demonstrated knowledge of managed care practices, medical claims management and business operations
• At least 3 years’ managerial experience in a medical insurance company
• At least 2 years’ experience in a busy clinical setting
• Addressing operational concerns and issues, monitoring overall customer satisfaction.
• Developing and implementing operational procedures and policies

QUALIFICATIONS

• Bachelor’s degree in a Business-related field or Degree in medicine/pharmacy/nursing
• Postgraduate qualification in healthcare management, health systems management, health economics or business administration (MBA)
• Diploma or Certificate in Insurance will be an added advantage