Key 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 riskHolding 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.Reviewing of the outstanding claims regularly and monitoring team adherence to claims payments Turn Around Time (TAT).Oversee the business document management process to ensure prompt scanning of claims documents and indexing in the relevant systems.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 service provider reconciliations, processing & release of payments.Maintaining strong working relationships with service providers, Intermediaries, Clients, all departments and all business stakeholdersWork closely with ICT and Business analysts for any decision making on implementation of system requirements for claims cost management.Complying with statutory, regulatory and internal control processes at the business units including internal & external audits recommendations.Entrenching performance-based appraisal of departmental staff in line with their set KPI's and departmental targets.Any other roles assigned by management from time to timeSkills and Competencies RequiredStrong leadership and management skillsAbility to work independently and build effective interpersonal relationsBias towards innovation and development of new ideas in problem solvingProfessionalism in dealing with both internal and external stakeholdersExcellent communication and negotiation skills.Extensive networking with service providers and other medical insurersExcellent analytical and monitoring skillsAbility to evaluate decisions made in benefit utilization managementIntegrity and honestyKnowledge & ExperienceDemonstrated knowledge of managed care practices, medical claims management and business operations.At least 3 years' managerial experience in a medical insurance environmentAddressing operational concerns and issues, monitoring overall customer satisfaction.Demonstrated experience engaging service providers at high level, and experience negotiating claims handling terms with providersDeveloping and implementing operational procedures and policiesAcademic and Professional Qualifications requiredDegree in medicine/pharmacy/nursing or Business-Related fieldACII or DIP AIIK or CIM qualificationsMaster's Degree is an added advantage
