Assistant Director, Claims Management - 2 Posts at The Social Health Authority (SHA)

Qualifications, Skills and Experience Required:

Promotional - Claims Management (Medical Review): 

• Cumulative service period of twelve (12) years relevant work experience, three (3) of which should have been at the grade of Principal Claims Management Officer or a comparable position.
• Bachelor’s Degree in Medicine and Surgery from a recognized institution.
• Master’s Degree in Medicine and Surgery from a recognized institution.
• A valid practicing license from a recognized institution.
• Certificate in Leadership course lasting not less than four (4) weeks from a recognized institution.
• Proficiency in computer applications.
• Demonstrated managerial, administrative, and professional competence in work performance and results.

Responsibilities:

• Coordinating medical reviews and interpretation of medical reports.
• Coordinating the reviewing, processing, and validating of medical claims from healthcare providers and facilities for accuracy and adherence to policies.
• Coordinating the appraisal of medical claims based on the benefit package to ensure fair and timely disbursement of funds.
• Ensuring issuance of pre-authorizations for access to healthcare services.
• Maintaining and operationalizing an e-claims and case management system.
• Ensuring sensitization of claimants on the consequences of submitting false and fraudulent claims.
• Coordinating the collection and analysis of data for claim management to inform strategic decisions.
• Preparing quarterly reports on claims for submission to the Board and Cabinet Secretary.
• Carrying out any other necessary functions for the Authority’s mandate.
• Coordinating the management of contracted and outsourced claims management services.
• Coordinating quality assurance surveillance to identify gaps and recommend corrective actions.