datatrota
Signup Login
Home Jobs Blog

Medical Data / System Claims Analyst

Old Mutual KenyaNairobi, Kenya
Full Time
Old Mutual Kenya is based in Nairobi and is part of a larger group that offers solutions in long-term savings, asset management and investment. We offer solutions to individuals and corporates underpinned by our core values which are: Respect, Integrity, Accountability and Pushing beyond boundaries.

Job Description

Responsible for ensuring claims processes and services meets the established standards to guarantee efficiency /accuracy by utilizing data analysis and technology to improve claims processing by monitoring and establishing controls for the management of claims costs.

KEY TASKS AND RESPONSIBILITIES

Overseeing Claims Processes:

  • Monitor and evaluate the entire claims processing lifecycle to ensure adherence to established standards and procedures.
  • Identify areas for improvement in claims processing workflows and implement enhancements.
  • Overseeing the claims team addressing the claims backlog, Smart EDI champion and the unregistered claims docket and ensure they deliver set target.

Data Analysis:

  • Utilize data analysis tools and techniques to assess claims data, identify trends, anomalies, and opportunities for cost-saving measures.
  • Develop reports and dashboards to present data-driven insights to management.

Efficiency Improvement:

  • Collaborate with cross-functional teams, including claims processors, IT, and data analysts, to streamline claims processing procedures.
  • Implement technology solutions to automate manual tasks and reduce processing times.
  • Gather requirements and assist in building and documenting specifications for development (future projects or system upgrade).
  • Troubleshoot system issues and follow up to ensure resolved by the specific stakeholders i.e., IT / Smart etc.

Accuracy and Quality Assurance:

  • Implement quality control measures to ensure claims are processed accurately and in compliance with industry regulations i.e., Vetter’s Rejection rate / Adherence to the recommendations.
  • Conduct audits and quality checks to identify errors and discrepancies in claims processing.

Cost Management:

  • Develop and implement cost-containment strategies and controls to reduce claims costs while maintaining quality services.
  • Analyze cost-related data to identify areas for cost reduction and optimization.

Standardization and Compliance:

  • Ensure that claims processes adhere to established standards, policies, and regulatory requirements.
  • Keep abreast of changes in regulations and industry standards and update processes accordingly.

Documentation and Reporting.

  • Maintain detailed records of claims processes, controls, and improvements.
  • Prepare and present reports outlining process efficiency, cost-saving measures, and compliance.
  • Recommend system changes/enhancement upon evaluation of the end-to-end claims processing value chain.

Communication and Training for both Internal and External clients:

  • Collaborate with team members to communicate process changes and improvements effectively.
  • Provide training and support to claims processing staff to ensure they follow established procedures.
  • Ensure timely completion of investigations/resolution arising from claims disputes raised by clients in case management and claims teams.

Computation of discount

  • Compute the correct provider discount and advisethe finance team.
  • Ensure that discount calculation timelines are met.

Support with data clean up.

  • Ensure that client data is accurate in all systems.
  • Capture the correct provider details while onboarding them.
  • Assist in membership correction to ensure that claims are paid on time and to the correct provider for the correct members.

 SKILLS AND COMPETENCIES

  • Decision Making,
  • Client Focus,
  • Information Monitoring,
  • Gaining Commitment
  • Team Orientation
  • Initiating Action
  • Analytical skills
  • Problem solving skills

 KNOWLEDGE & EXPERIENCE

  • Technical Knowledge
  • At least 3 years’ experience
  • Proficiency in data analysis tools and software (e.g., Excel, SQL, data visualization tools).
  • Knowledge of claims processing procedures and industry standards.
  • Proficiency in using computer software and claims processing systems.

 QUALIFICATIONS

  • Bachelor's degree in a related field, such as business administration, finance healthcare management, or data analysis, is preferred. Medical background
  • Professional license
  • Experience in claims processing and vetting
  • Quality assurance experience will be an added advantage

Method of Application

Signup to view application details. Signup Now
X

Send this job to a friend