Claims Management Officer II Jobs at The Social Health Authority (SHA)

Minimum Qualifications:
Bachelors Degree
Job Term:
Permanent and Pensionable
Position Level:
SHA 8
Number of positions:
2

Qualifications, Skills and Experience Required:
For appointment to this grade, a candidate must have:
1. Bachelor’s Degree in Medicine, Nursing, Clinical Medicine, Medicine and Surgery or its equivalent from a recognized institution;
2. Membership to the relevant professional body and in good standing; and
3. Proficiency in computer applications.
Responsibilities:
You will be responsible for reviewing, processing, and validating medical claims, appraising claims based on benefit packages, issuing pre-authorizations, and undertaking quality assurance surveillance.
Officers in this cadre may be deployed to any of the following functional areas:-
• Claims Management
• Claims Management (Quality Assurance and Surveillance)

Claims Management

Key responsibilities

1. Carrying out the reviewing, processing, and validating of medical claims from healthcare providers and healthcare facilities under supervision;
2. Assisting in the appraisal of medical claims based on the benefit package to determine eligibility and prevent misuse;
3. Implementing the issuance of pre-authorizations for access to healthcare services based on the benefit package while ensuring compliance with procedures;
4. Assisting in the operationalization of an e-claims management system to facilitate accurate and efficient claims processing;
5. Collecting and analyzing data for purposes of claim management to enhance efficiency in claims processing; and
6. Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities.

Quality Assurance and Surveillance
Key responsibilities
1. Undertaking quality assurance surveillance in respect of claims to detect errors and inconsistencies;
2. Assisting in implementing systems and controls for detecting and identifying fraud appropriate to the Authority’s exposure and vulnerability;
3. Supporting the sensitization of claimants on the consequences of submitting false and fraudulent claims to reduce fraudulent activities;
4. Undertaking compliance monitoring and quality assurance activities in assigned regions.
5. Supervise clinical audits and develop corrective action plans for non-compliance.
6. Coordinating the implementation of Hospital Quality Improvement Teams (HQITs);
7. Monitoring benefit utilization and accessibility trends within the region; and
8. Developing detailed reports on compliance trends and recommend strategic interventions.