Medical Jobs In Kenya.

Case Manager/Claims Analyst

Date Posted: 02 Mar 2023 | Expires on: 08 Mar 2023

PACIS Insurance Company Limited  was incorporated in Kenya in October 2004 and licensed to do business in August 2005. The Catholic Church mooted the idea of the formation of the company in 1997 as one of the mechanisms of ensuring sustainability in funding of Catholic Church projects. This is through the various Archdioceses, Dioceses, the Catholic Missionary Priests, and the Association of the Catholic Nuns together with affiliated institutions of the Church who are the main sponsor of the Company.

Pacis Insurance offers financial solutions for both general and medical insurance specific to the unique customer needs for corporates, retail, and other organized groups in remaining true to its vision of offering comfort and peace to society. In response to these ever-changing customer needs, Pacis Insurance is on a growth strategy to optimize the existing market opportunities for to increase customer and shareholder value. Pacis therefore seeks to recruit a  Case Manager/Claims Analyst.

Purpose of the job 

Collaborate with medical clients, intermediaries, and medical service providers to facilitate access to quality, timely, effective, and cost-efficient healthcare services with the aim of achieving business growth, profitability, and customer retention.

Principal Accountabilities 

Claims Processing

• Confirmation of membership, validity, and benefits before processing claims.
• Capture and vet medical bills within the clients benefit structure.
• Code, verify, audit and process medical claims within negotiated, customary and reasonable price.
• Correctly reserve bills on discharge and approved outpatient cases.
• Provide second review of bills where providers question the appropriateness of payment authorized.

Care Management

• Review pre-authorization of admission, discharges, scheduled and emergency medical cases, issue timely responses as per policy benefits and company guidelines.
• Review of patient’s history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.
• Coordinate local and international emergency evacuations, referrals, and transfers
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.
• Negotiation of doctors’ and hospital bills and charges in view of reducing the cost of care before or during admissions.
• Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi. Post discharge follow up of patients to ensure adherence to care.
• Follow up care of admitted patients with the doctors and providers to ensure quality care and cost containment.
• Implement preventive care program through health talks, wellness and the chronic disease management program CDMP.
• Send weekly and monthly report on admissions, exceptional claims, long stay, savings amongst others.
• Audit service provider applications, process contracts and provider feedback

Customer Service

• Oversee weekly sending out active members list to the providers.
• Update intermediaries and/ or scheme administrators on clinical, coverage and bills of admitted clients.
• Provide feedback and update to intermediaries and schemes on requested providers.
• Coordinate with the clients and medical providers to leverage on NHIF.
• Ensure adherence to contracts and service level agreements between providers and the company.
• Process reimbursement documents and communicate to clients about the status of their claims.
• Register, follow through and resolve the customers and provider queries and complains in time and advise them on outcome and the details of the medical product.

Knowledge and experience

Qualifications:

Academic Qualification

• Bachelor’s degree Nursing/ Diploma in Nursing

Professional Qualifications

• Nursing Council of Kenya
• AIIK

Experience:

• Four years’ experience in health insurance

Knowledge

• Understanding of insurance industry

Skills & competencies

• Excellent communication and Interpersonal Skills.
• Problem Solving
• Empathy
• Decision Making
• Negotiation Skills
• Ethical
• Team Player
• Keen to detail
• Planning & Organization Skills
• Customer Oriented
• Stakeholder management
• Dependability

How To Apply

Applications with a detailed CV, indicating your telephone contacts with names and addresses of three referees should be emailed to [email protected]  not later than  Thursday 9th March 2023.

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