Reporting to the health care Administrator-Bancassurance, the role holder will be responsible for day-to-day engagement with medical providers to ensure quality healthcare provision to schemes members. Preparation of summary reports to guide on settlement or decline of claims submitted by scheme members or healthcare providers and to support medical underwriting function in reviewing of pre-requisite medical examination reports for KBIL healthcare products to facilitate placement of medical policies with respective underwriters.

Key Responsibilities

• Vetting and analyzing medical claims as per scope of cover whilst ensuring strict adherence to set guidelines and TAT.
• Monthly tracking of insured reimbursement claims with respective underwriters for payment.
• Medical call center management of providers preauthorization, members enquiries and emergency evacuation for medical scheme members.
• Preparation of utilization reports and other reports as required by member / clients.
• Reconciliation of reimbursement claims and ensuring all the claims are paid within the agreed TAT.
• Monthly reconciliation and sign off of healthcare providers accounts including visits to providers to sort out contagious bills/issues.
• Updating staff medical statements and ensuring all utilizations are captured on a timely basis.
• Professional assistance to scheme members with chronic ailments and facilitating follow up with specialists’ clinics including facilitation to overseas treatment.
• Hospital visits for scheme members and preparation of members’ admission reports and update to schemes administrators.
• Ensure that all medical related customer queries, problems, and complaints are fully resolved within the set guidelines and TAT.

The Person

For the above position, the successful applicant should have the following:

• A bachelor’s degree in nursing 
• At least 2 years experience in Care Management in a Medical Insurance setting