Assistant Director, Claims Management – 2 Posts at The Social Health Authority (SHA)

Job Description

Qualifications, Skills and Experience Required:

Promotional – Claims Management (Medical Review):

Cumulative service period of twelve (12) years relevant work experience, three (3) of which should have been at the grade of Principal Claims Management Officer or a comparable position.
Bachelor’s Degree in Medicine and Surgery from a recognized institution.
Master’s Degree in Medicine and Surgery from a recognized institution.
A valid practicing license from a recognized institution.
Certificate in Leadership course lasting not less than four (4) weeks from a recognized institution.
Proficiency in computer applications.
Demonstrated managerial, administrative, and professional competence in work performance and results.

Responsibilities:

Coordinating medical reviews and interpretation of medical reports.
Coordinating the reviewing, processing, and validating of medical claims from healthcare providers and facilities for accuracy and adherence to policies.
Coordinating the appraisal of medical claims based on the benefit package to ensure fair and timely disbursement of funds.
Ensuring issuance of pre-authorizations for access to healthcare services.
Maintaining and operationalizing an e-claims and case management system.
Ensuring sensitization of claimants on the consequences of submitting false and fraudulent claims.
Coordinating the collection and analysis of data for claim management to inform strategic decisions.
Preparing quarterly reports on claims for submission to the Board and Cabinet Secretary.
Carrying out any other necessary functions for the Authority’s mandate.
Coordinating the management of contracted and outsourced claims management services.
Coordinating quality assurance surveillance to identify gaps and recommend corrective actions.