Deputy Director Claims & Case Management at The Social Health Authority (SHA)

JOB PROFILE

The Deputy Director, Claims and Case Management will provide strategic leadership in the administration, processing, and resolution of health insurance claims within the Social Health Authority (SHA). This role is responsible for developing and implementing claims management policies, ensuring efficiency, accuracy, and compliance with the Social Health Insurance Act, 2023, and other regulatory frameworks. The position oversees claims adjudication, fraud detection and mitigation, dispute resolution, and case management to enhance service delivery and financial sustainability. Additionally, the role ensures seamless coordination with healthcare providers, members, and regulatory bodies to uphold transparency and accountability in claims processing.

QUALIFICATIONS

• Fifteen (15) years cumulative experience, at least three (3) of which should have been at the level of Assistant Director or in a comparable position in the public or private sector.
• Bachelor’s degree in Medicine and surgery, from a recognized institution. 
• Master’s degree in Medicine and Surgery, or health-related fields from a recognized institution.
• Management course lasting not less than four (4) weeks from a recognized institution.
• Membership to the relevant professional body in good standing.
• Valid Practicing license.
• Demonstrate a clear understanding of the SHI Act, 2023, and other laws relevant to SHA operations.
• Meet the requirements of Chapter Six of the Constitution of Kenya.

Key Competencies and Skills

• Strong analytical skills
• Communication skills
• Strong interpersonal skills
• Negotiation skills

Responsibilities:

• Ensure strategic and operational planning for claims management, defining, risk assessments and monitoring progress against strategic objectives in collaboration with other departments;
•  Ensure Formulation and implementation of policies and strategies for effective and efficient claims management;
• Coordinate reviewing, processing and validating medical claims from healthcare providers and healthcare facilities;
• Ensure issuing of pre-authorizations for access to healthcare services based on the benefit package;
• Ensure appraising medical claims based on the benefit package;
• Coordinate quality assurance surveillance and claims adjudication in respect of claims;
• Establishing systems and controls for detecting and identifying fraud appropriate to the Fund’s exposure and vulnerability in collaboration with other departments
• Oversee Sensitization of claimants on the consequences of submitting false and fraudulent claims;
• Ensure effective collection and analyzing of data for purposes of claim management in collaboration with other departments. 
• Coordinate collaborations with relevant entities in the Health Needs Assessment for clinical interventions and other technologies;
• Ensure preparation of reports on claims 
• Ensure effective implementation and continuous improvement of Claims management information systems, ensuring they support efficient operations and member satisfaction in collaboration with the relevant entities in collaboration with other departments. 
• Establish and refine robust internal claims management controls to safeguard the sustainability, affordability, and integrity of benefits packages for all stakeholders. 
• Ensure compliance with local and international standards in Claims Management (as prescribed in the Act), fostering alignment with globally recognized best practices and enhancing the Authority’s reputation.
• Ensure the development and execution of policies and strategies for business process re-engineering, driving innovation and efficiency in Claims Management.
• Provide expert guidance in Claims management on reviewing and amending the Social Health Insurance Act, ensuring responsiveness to the evolving healthcare landscape and adherence to quality standards.