Reports to: Assistant Manager, Health Business
Location: Kampala, Uganda
Our client is a wholly-owned comprises of a portfolio of businesses focused on structural growth markets. The business helps individuals to de-risk their lives and deal with their biggest financial concerns through life insurance. One of the longest standing and most successful global insurers in the world with over 20 million life customers, +24,000 employees and £56 billion of assets under management as at 30th June 2019.
It has been providing financial security to customers since 1848 and it’s one of the oldest insurers in the world, with 171 continuous years of providing financial services. The firm is listed on stock exchanges in London, Hong Kong, Singapore and New York.
Provides protection and savings opportunities to customers, social and economic benefits to the communities in which it operates, jobs and opportunities to its employees and financial benefits for its investors. By offering security, pooling savings and making investments, the firm helps to maintain the cycle of growth. The company’s strategy is designed to create sustainable economic value for its customers and shareholders.
The company continues to develop its businesses in new markets in Africa, building on the success of its other regional models, particularly Asia. Currently, the company has a footprint in eight countries: Uganda, Kenya, Zambia, Ghana, Nigeria, Cameroon, Cote d’ Ivoire and Togo.
The Medical Claims Officer reports directly to the Assistant Manager, Health Business of Health Insurance Business and will be part of the Operations team.
The incumbent will have responsibility for the claims function with in the health insurance business at Prudential Uganda.
This will include ultimate accountability for price negotiation with HCPs, authorising the Health care service provision extended to PAUL’s patients, offering clinical support to the other functions of the health insurance business and managing the entire claims administration process.
The successful applicant will have clinical qualifications and experience and having also worked in a reputable and licensed medical facility.
• Managing the entire claims process from receiving, batching, scanning, processing, vetting, payment and ensuring that the set turnaround times are met.
• Providing claims data and trends to management to assist in product reviews and decision making
• Handle the medical line and respond to HCPs and Prudential clients who need assistance .Review pricing list for new HCPs
• To effectively communicate and respond to medical issues or queries arising out of the vetted bills or claims including reconciliation of all disputed claims with the affected medical centres. • Reviewing of regular reconciliations of paid /rejected claims for each HCP based on the information included in the claim system and following up on rejected claims with each HCP. • To respond in a timely, efficient, professional manner to pre-authorisation. • Advise on medical queries to facilitate informed decision making on benefits, authorisations etc.
• To carry out clinical audits as requested by PruMed management for long stay admissions, clients requiring unusual treatment and advice accordingly on way forward.
• To respond to all pre-authorisations sent to PruMed by HCP’s for medical treatment especially for specialised, treatment out of service network and inpatient and surgical care. • At times keep updated on new treatment protocols nationwide and world over by attending CME’s and organising them within the department.
• Carry out field visits to the HCPs to audit the quality of services that they offer to PruMed clients, the work place and other aspects of service provision. These should be in line with the principles of Patient Safety, Quality of Care and Customer Satisfaction.
• Following audit, to make recommendations about the various HCPs that are accessed by clients.
o Carry out HCP visits to admitted patients for the purposes of making recommendations for treatment according to the National guidelines
o Making sure that treatment costs are within the approved benefit balances o Making sure that all patients are getting the best care available
o Answering any queries that the HCP or the clients may have regarding the admission o Making sure that the admission or treatment given is within the scope of cover as per the clients contract
• Receive, vet and keep record of all HCP price lists and make price list comparisons with the clinic network with in regions and compiling drug formularies and price lists.
• Carry out HCP profiling according to the availed guidelines for contracting purposes by; o Visiting the proposed HCP and carry out an audit of the standards of care when called upon receiving and vetting the provided price lists.
o Receiving all necessary documentation to aid the contracting process i.e., trading licence, practicing licenses, tin Certificate, certificate of incorporation, banking details etc.
• Handle, process all individual claims as per the guideline in liaison with the Finance Officer • Receive all invoices from the HCPs and initialise accordingly, making sure that all statements of accounts are reconciled from time and especially by half and close of year. • Maintaining regular reports on claims experience data covering HCPs (e.g. higher than average use of certain tests or follow-up referrals.)
• Generate weekly ,monthly and annual reports which include :
o Claims vetted including amounts for approved, rejected and on hold claims. o Client and HCP visits carried out and findings
o Pre-authorisations done
o CME Report.
• To undertake any other duties at the request of the line manager, which are commensurate with the role, including project work, internal rotation and absence cover.
Core Competences Required:
• University Degree and or Diploma in a medical related course, from a recognized University or Institution.
• Ability to multitask
• Ability to work productively with in a team
• Ability to work under pressure and meet deadlines.
• Demonstrate the ability to pay attention to details.
• Good computer skills i.e. Microsoft Word and Microsoft Excel
• Good customer care and people skills
• Have a creative and practical approach to your work.
• Have a high degree of flexibility
• Should be a team player
• Solid analytical and problem solving skills
• Strong written and oral communication skills. \
• Negotiation skills