Old Mutual Kenya 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: Respect, Integrity, Accountability, and Pushing beyond boundaries.
A Claims Analyst is responsible for accurately capturing claim details into the system, verifying documentation, ensuring policy compliance, and flagging inconsistencies to facilitate efficient claims processing and minimize errors.
Key Tasks and Responsibilities
Claim Evaluation: Evaluate inpatient and outpatient medical claims for completeness and accuracy. Verify that claimed services are medically necessary, correctly coded, and fall within the policy scope.
Compliance & Verification: Cross-check claims against policy benefits, exclusions, and pre-authorizations. Confirm that claim documents (invoice, claim form, SHIF deduction, pre-authorization, discharge summary, etc.) are complete and properly attached.
Data Management: Accurately capture and update claim data in the claims management system (inpatient, outpatient, maternity, dental, optical, etc.). Ensure all required fields (member details, provider details, ICD-10 codes, CPT codes, amounts, etc.) are correctly filled.
Reporting: Generate daily, weekly, and monthly reports on claims trends, rejections, and approvals. Maintain daily logs of claims captured per source/provider.
Fraud & Risk Management: Flag and escalate abnormal utilization patterns or possible fraud cases. Check for duplication of claims or repeated submissions and flag them appropriately.
Collaboration: Work closely with underwriting, CXC, and finance departments. Participate in weekly performance reviews to track accuracy and productivity.
Processing: Process off-smart claims and claims that failed to get pushed by smart through the lite link. Handle cancelled claims such as scheme reversals, wrong membership, wrong provider, wrong currency, or wrong benefits.
Documentation: Index all claims and ensure physical and scanned copies are properly organized and linked for audit readiness.
Qualifications and Requirements
Education: Bachelor's Degree (BA/BSc) or Higher National Diploma (HND) in a relevant field.
Knowledge: Understanding of insurance claim processing workflows and medical insurance policy limits.
Technical Skills: Familiarity with ICD-10 and CPT coding and insurance claims management software.
How to Apply
Interested and qualified candidates should apply online through the Old Mutual career portal at oldmutual.wd3.myworkdayjobs.com.
How to Apply
Interested and qualified candidates should apply through the Old Mutual Workday career portal: Apply Here. Alternatively, visit the application link provided on the listing page: https://www.myjobmag.co.ke/apply-now/1184147
