Reporting to the Senior Health Risk Officer and the main purpose of the job is to provide sound risk management by working daily with other functional staff to assess potential and inherent or actual risks pertaining to the business and mainly related to Claims Management processes. This will involve analysing high-risk claims operations processes and building risk awareness amongst staff by providing support and training within the company.
Principle Accountabilities for this role include but are not limited to the following:
i. Claims Management (60% weight)
⦁Coordinate the collection of risk information from source systems, departments and reports.
⦁Maintain a risk register for documenting risks and actions to manage each risk.
⦁Building risk awareness amongst staff by providing support and training within the function.
⦁Assist in the development and monitoring of key risk indicators (KRI) that are mapped to
various risks to determine elevations in risk and proactively implement risk mitigation measures.
⦁Periodically profile claims processes to ensure adherence to laid down claims business rules and standard Operating Procedures.
⦁Interrogate claims patterns from various claims data sources with an aim to identify outliers and put in place control measures.
⦁Working closely with Senior – Health Risk Officer, ensure availability of updated Unit
⦁Management Reports dashboards.
ii. Claim Settlements and Reconciliations (40% weight)
⦁Conduct 1st line Risk check of all Pre and Post Payment runs.
⦁Participant in Post payment run claims batching processes to help with timely primary identification of outliers.
⦁In close collaboration with Claims and Finance Reconciliation team, review all redirected bills and recoveries processes.
⦁In close collaboration with Claims and Finance Reconciliation team, participate in Provider training sessions, especially on risk mitigation issues.
⦁Prepare Weekly/Monthly & adhoc claims Risk Management status reports on to help timely intervention on any identified gaps.
⦁Participate in any other claims process roles as demand arises and as guided by the Supervisor
⦁Executing any other tasks and assignments that may be delegated by the supervisor from time to time.
⦁Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language.
⦁Must have a Degree in Healthcare Management or any related field.
⦁Certificate or Diploma in Health Insurance, Compensation fund or any social security is an added advantage.
⦁At least one (1) year working experience in a similar role.
⦁Extensive knowledge of the Insurance industry.
⦁Overall understanding of Health Care provider operations and medicine and treatment procedures.
⦁Financial acumen.
⦁Attention to detail, strong analytical and decision-making skills.
⦁Strong problem-solving and decision-making abilities, and ability to work under pressure
⦁Good oral and written communication skills.
⦁Proficiency in office applications such as Excel, Word, PowerPoint, and many other relevant applications.
⦁Must have good interpersonal skills.
⦁Must have strong influencing and negotiation skills.
⦁Ability to work with limited supervision and highly organized.
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