Reporting Structure

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Job Requirements

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Main Duties

Job Purpose

• The role incumbent is responsible for processing medical claims with a focus in controlling and managing member benefits through vetting of inpatient and outpatient bills. He is also responsible for the recruitment of new service providers and maintaining the relationship with service provider; case management; maintaining the hotline and dealing with approval requests from service providers.

Key Responsibilities

• Verify and capture outpatient and inpatient claims as per the claims manual.
• Assess medical claims documents for authenticity and process payments within set service levels
• Register and process all reported medical claims and advise clients on the required claims supporting documents
• Raise payment requisition within set standards
• Ensure all claims documents are archived appropriately
• Promptly and efficiently attend to customer queries and complaints
• Recruit service providers and maintain good relationship for smooth customer experience
• Make and sign off medical claims reconciliations with service providers to reduce company liability
• Assess and respond to service providers approval request within set service levels
• Make hospital visits for admitted patients to assess service satisfaction, patient prognosis and advise on interventions where necessary
• Any other duty as may be assigned from time to time.

Working Relationships Internal Relationships:

• Accountable to the Medical Manager
• Required to liaise and work closely with the other departments as may be necessary

External Relationships

• Britam Customers
• Insurance sector players

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Other Requirements

Knowledge, Experience And Qualifications Required

• Degree in health related field
• Professional qualification in Insurance (COP in Insurance)
• 2- 4 year's experience(experience in medical claims processing is an added advantage)

Essential Competencies Emerging Leaders Competency Descriptions.

• Learning and Researching - Rapidly learns new tasks and commits information to memory quickly; demonstrates an immediate understanding of newly presented information; gathers comprehensive information to support decision-making at management level; learns from successes and failures and seeks feedback from colleagues and customer.
• Working with People - Shows respect for the views and contributions of team members; shows empathy; listens, supports and cares for others; consults others and pro-actively shares information and expertise with them; contributes to team spirit and reconciles interpersonal conflict; adapts to the team and fits in well.
• Adhering to Principles and Values - Upholds ethics and values; demonstrates integrity; accepts diversity; displays individual responsibility towards the community and the environment; acts out the organisational values during everyday interactions.
• Applying Expertise and Technology - Applies specialist and technical expertise; uses technology to achieve work objectives; develops job knowledge and expertise (theoretical and practical) through continual professional development; demonstrates an understanding of different organisational departments and functions.
• Delivering Results and Meeting Customer Expectations - Focuses on customer needs and satisfaction; exhibits high standards for quality and quantity; monitors and maintains own quality and productivity; works in a systematic, methodical and orderly way; consistently achieves projects goals.
• Following Instructions and Procedures - Follows procedures and policies; keeps to schedules; arrives punctually for work and meetings; demonstrates commitment to the organisation; complies with legal obligations and safety requirements of the role.
• Achieving Personal Work Goals and Objectives - Accepts and tackles demanding goals with enthusiasm; works hard and puts in longer hours when it is necessary; seeks progression to roles of increased responsibility and influence; identifies and requests feedback regarding own development needs and makes use of developmental or training opportunities.
• Writing and Reporting- Writes convincingly; writes clearly, concisely and correctly; avoids the unnecessary use of jargon or complicated language; writes in a well-structured and logical way; structures information to meet the needs and understanding of the intended audience.
• Analysing - Analyses numerical data and all other sources of information, breaking them into component parts, patterns and relationships; probes for further information or greater understanding of a problem; demonstrates an understanding of how one issue may be a part of a much larger system.
• Planning and Organising - Adheres to clearly defined objectives; plans activities and projects well in advance and takes account of possible changing circumstances; identifies and organises resources needed to accomplish own tasks; manages own time effectively; monitors own performance against deadlines and milestones.
• Adapting and Responding to Change - Adapts to changing circumstances; tolerates ambiguity; accepts new ideas and change initiatives; adapts interpersonal style to suit different people or situations; shows an interest in new experiences.
• Coping with Pressures and Setbacks - Maintains a positive outlook at work; works productively in a pressurised environment; keeps emotions under control during difficult situations; handles criticism well and learns from it; balances the demands of work life and personal life.

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Location : Tanzania: Dar es salaam Dar Es Salaam
Industry :Insurance
Company : Britam