Principal Claims Management Officer - 15 Posts at The Social Health Authority (SHA)

Qualifications, Skills and Experience Required:

Promotional-Claims Management-Medical Review: 

• Cumulative period of services of nine (9) years of work experience, three (3) of which should have been at the grade of Senior Claims Management Officer or in a comparable position.
• Bachelor’s Degree in Medicine and Surgery from a recognized institution.
• A valid practicing license.
• Certificate in Management course lasting not less than four (4) weeks from a recognized institution.
• Membership to the relevant professional body and in good standing.
• Proficiency in computer applications.
• Shown merit and ability as reflected in work performance and results.

Responsibilities:

• Undertaking medical reviews and interpretation of medical reports.
• Undertaking reviewing, processing, and validating of medical claims from healthcare providers and facilities for accuracy and adherence to policies.
• Undertaking the appraisal of medical claims based on the benefit package to ensure fair and timely disbursement of funds.
• Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package to facilitate timely service provision.
• Collecting and analyzing data for the e-claims and case management system to enhance efficiency and accountability.
• Conducting quality assurance surveillance in respect of claims to ensure adherence to policies and detect irregularities.
• Carrying out sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.
• Collecting and analyzing data for purposes of claim management to facilitate informed decision-making and continuous process improvement.
• Collating and analyzing of data for preparation of quarterly reports on claims for submission for transparency and accountability.
• Ensuring compliance with contractual obligations contracted and outsourced claims management services.