Quality Assurance Officer - Health at Old Mutual Kenya

Job Description

The Health Insurance QA Officer is responsible for ensuring the accuracy and compliance of health insurance claims processing within the organization. This role involves reviewing claims, identifying errors or issues, and implementing corrective actions to improve quality assurance processes.

KEY TASKS AND RESPONSIBILITIES

Quality Audits Of Claims.

• Identify Providers with significant billing irregularities or suspected of fraud and have regular provider engagement issues on billing.
• Review claims that relate to benefit excesses, assign liability, and recover while ensuring the root cause is addressed.
• Admissions tracking; checking on exaggerated bills, unnecessary admissions or overstay admissions, and doctors’ charges.
• Review system rejections of claims for root causing and resolution.
• Quality audits on the vetters and ML module to identify quality gaps and remediate them.
• Identify and investigate any errors, discrepancies, or quality issues in the claims processing procedure
• Collaborate with various departments (e.g. underwriting, provider relations, IT) to resolve complex claims issues

Reporting and Trend Analysis.

• Prepare objective reports on processes that lead to leakages and proposed mitigative measures.
• Review claims, and provide recommendations to claims, retention, case, and provider relations teams on trends noted: both from users and providers.
• Make recommendations to management regarding developing policies, processes, and procedures; identify and implement processing efficiencies; identify trends and continuing education opportunities.
• Manage reserve philosophy for admission/approved and or enhanced amounts through weekly audits to ensure the acceptable threshold is being met.
• Review reimbursement reports to pick exceptions and cold calling/impromptu visits to validate.
• Conduct regular process audits to enforce adherence to laid out SOPs across the health business
• Maintain proper documentation of call performance and associated corrective measures as applicable

Training and Feedback

• Designing effective training programs and collaborating with trainers to ensure the feedback loop from the QA audits is complete.
• Identify knowledge gaps and training needs of the relevant teams and hold calibration sessions and breakout training sessions as needed.
• Develop and implement quality control measures to prevent future errors and improve efficiency
• Stay up-to-date with changes in healthcare laws, regulations, and best practices related to claims management

Monitor and support risk management activities: GIA issues

• Prepare regular claims reports to management and advise on relevant claims findings for medical risk review.
• Ensure all audit items are closed in your respective area.

Systems Enhancement

• Continuously review the effectiveness of workflow systems and recommend enhancements.
• Provide input on ML and core system enhancements to improve quality and output.

Any other tasks/duty as may be assigned by the Line manager.

SKILLS AND COMPETENCIES

Competences

• Proficiency with claims management software and data analysis tools
• Motivated team player who is detail-oriented.
• Excellent communication skills, both written and verbal 
• Strong working knowledge of the Microsoft suite of products 
• Strong analytical, problem-solving and decision-making abilities.

Qualifications & Requirements

• 3+ years experience in Quality Assurance/Medical claims/Case management
• Bachelor’s Degree or Diploma in Nursing/Clinical Medicine
• Experience working in the Insurance industry preferred.
• Additional insurance qualifications will be an added advantage