Job Description

Heritage Insurance Head of Claims and Care Management Job in Nairobi, Kenya 2019

Career Employment Head of Claims and Care Management Nairobi Kenya April 2019 

Heritage Insurance Company

Job Title: Head of Claims and Care Management

Reports To: Director – Health Insurance

Location: Head Office, Nairobi

About Heritage: We are a leading Insurance Company, affiliated to Liberty Group, a wealth management company represented in 18 African countries. We use our knowledge and action to guide our customers on their journey to financial freedom. We believe in responding to the changing consumer and market needs through innovative solutions and technologically efficient processes.

Job Summary: The main purpose of the job is to ensure that Heritage customers receive quality healthcare at an affordable price and to oversee the activities relating to medical claims settlement.

Key Responsibilities

Claims Management:

• Develop the claims management strategy for health business that ensures medical claims management contributes to the profitability of the business


• Develop policies and procedures that guide the delivery of medical claims management services to support profitability and compliance with the relevant insurance regulations


• Develop processes for claims management to support efficiency and effectiveness in delivering quality customer service in line with the Heritage values


• Co-ordinate and maintain expeditious and efficient processing of medical claims and ensure customer needs are attended to promptly


• Review claims processed to ensure that all claims fall within scope of respective medical insurance policy and are in compliance with Heritage claims management policies and procedures, and to ensure only qualified medical claims are paid out.


• Monitor the trends in the claims submitted for analysis against those paid in order to develop a strategy that advises the business on how to organize claims management in support of profitability


• Develop and implement a records management plan for claims management including automation to ensure ease in availability and accessibility of claims management records for timely service delivery;


• Conduct a regular review of the claims process to identify gaps to be addressed in order to enhance profitability as well as efficiency and effectiveness in the claims management process


• Attend to escalated and complex medical claims to ensure these are attended to in a timely manner, and that they do not expose the business to any risk;


• Analyse medical claims data to identify issues, and ensure that all relevant issues relating to underwriting policies and product pricing are identified and communicated to relevant stakeholders.

Care Management

• Enhance customer experience – Establish and maintain good relationships with internal and external stakeholders such as health care service providers, brokers, agents and policy holders etc. Source analyze and provide relevant management information as required to appropriate parties for effective and efficient decision making.


• Digitize our processes for provision of member information requirements that include health tips.


• Ensure inculcation of the TCF (Treating Customers Fairly) culture.


• Develop a preventive care program through health talks, wellness programme that is a key component of our value proposition and Chronic Disease management.


• Incentivize the insured to maintain performance at the target MLR per product.


• Monitor existing scheme performance to achieve medical loss ratio of 75% on Flexi & 66% on Blue Class


• Develop and maintain thorough pre-authorization and care management processes to ensure accurate decisions on levels of care and the provision of appropriate treatment to patients.


• Provider management – Develop and maintain an efficient and effective health provider network that delivers access to a healthcare service that is affordable and appropriate.


• Contact centre management – Ensure that the medical contact center is effectively managed by ensuring that all responses to clients are professional, accurate and timely including prompt and efficient handling of all calls outside the Contact Centre hours.

People Management

• Develop staff members by sharing knowledge, mentoring, coaching and training and to ensure full range of performance management processes and procedures.

Qualifications

• Degree or Diploma in Medicine, Nursing, Clinical Officer or Pharmacy


• Professional qualification in Insurance (AIIK or ACII) will be an added advantage

Experience

• 7 years in health insurance operations 3 of which must be in a managerial role

Competencies

• Knowledge of insurance industry and concepts


• Customer, market and competitor understanding


• Knowledge of insurance regulatory requirements


• Formulation of strategies and concepts


• Business management skills


• Strong personality with interpersonal sensitivity


• Leadership skills


• Quality decision making skills


• Listening skills


• Conflict handling skills


• Presentation skills


• Good written and verbal communication skills


• Proactive


• Team player


• Strong negotiation skills


• Creative & open-minded


• High level of numeracy and strong analytical skills

Application Procedure

If you meet the above requirements you are encouraged to forward your application and updated CV to vacancies@heritage.co.ke by 14th April, 2019.

Clearly state the job title on the subject heading.

Heritage is an equal opportunity employer and actively encourages diversity.

Please note that only shortlisted candidates will be contacted.

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