Job Purpose

The role holder is responsible for processing medical claims with a focus on controlling and managing member benefits through vetting inpatient and outpatient bills. The position also involves recruiting new service providers, maintaining provider relationships, case management, managing the hotline, and handling approval requests from service providers.

Key Responsibilities

• Verify and capture outpatient and inpatient claims in accordance with the claims manual.
• Assess medical claim documents for authenticity and process payments within set service levels.
• Register and process all reported medical claims and advise clients on required supporting documents.
• Raise payment requisitions in line with set standards.
• Ensure all claims documents are properly archived.
• Promptly and efficiently attend to customer queries and complaints.
• Recruit service providers and maintain strong relationships to ensure smooth customer experience.
• Prepare and sign off medical claims reconciliations with service providers to reduce company liability.
• Assess and respond to service providers’ approval requests within set service levels.
• Conduct hospital visits for admitted patients to assess service satisfaction, patient prognosis, and recommend necessary interventions.
• Perform any other duty assigned from time to time.

Working Relationships

Internal Relationships

• Reports to the Medical Manager.
• Required to liaise and collaborate with other departments as necessary.

External Relationships

• Britam customers
• Insurance sector players

Knowledge, Experience, and Qualifications Required

• Degree in a health-related field.
• Professional qualification in Insurance (COP in Insurance).
• 2–4 years’ experience (experience in medical claims processing is an added advantage).

• Verify and capture outpatient and inpatient claims in accordance with the claims manual.
• Assess medical claim documents for authenticity and process payments within set service levels.
• Register and process all reported medical claims and advise clients on required supporting documents.
• Raise payment requisitions in line with set standards.
• Ensure all claims documents are properly archived.
• Promptly and efficiently attend to customer queries and complaints.
• Recruit service providers and maintain strong relationships to ensure smooth customer experience.
• Prepare and sign off medical claims reconciliations with service providers to reduce company liability.
• Assess and respond to service providers’ approval requests within set service levels.
• Conduct hospital visits for admitted patients to assess service satisfaction, patient prognosis, and recommend necessary interventions.
• Perform any other duty assigned from time to time.

• Medical claims processing
• Customer service
• Provider relationship management
• Case management

• Degree in a health-related field
• Professional qualification in Insurance (COP in Insurance)