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Quality Assurance Manager - Health at Old Mutual Kenya | Ajira Zone
Old Mutual Kenya
Quality Assurance Manager - Health Insurance Full-Time Mid-level(3-5 yrs)
Job Description About the Role
Old Mutual Kenya is seeking a Quality Assurance Manager - Health to be based in Nairobi. The Quality Assurance Manager - Health role involves overseeing quality audits of claims, analyzing trends, identifying leakages, and ensuring compliance with healthcare policy terms. The position focuses on claims cost controls, system enhancement, risk management, and training.
Key Tasks and Responsibilities
Quality Audits of Claims
Conduct an audit of overall claims settled, placing special attention on high-value, repeated visits, and duplicate claims. Check error rates.
Identify Providers with significant billing irregularities or suspected fraud and perform regular provider engagement on billing.
At the end stage of provider reconciliation, review claims that relate to benefit excesses and assign liability to either UAP, client/scheme, or Smart.
Track admissions; checking on exaggerated bills, unnecessary admissions, or overstay admissions.
Review the integration exception report between E02 and D365.
Trending Analysis & Cost Control
Conduct trending analysis, identify leakage, and prepare objective reports on claims and case processing processes.
Enforce claims cost controls, e.g., copayments, discounts, provider restrictions, and waiting periods.
Monitor and ensure compliance with SOPs for claims, case, and provider management.
Manage reserve philosophy for admission/ approval and enhanced amounts.
Review IP bills for scheduled cases on a monthly basis.
Review reimbursement reports to pick exceptions and conduct cold calling/impromptu visits.
Training & Capability Building
Contribute to the development of process-specific, competency-based training.
Identify knowledge gaps and training needs of the claims and case team.
Identify gaps in policy terms and review together with the retention team.
Give recommendations and remedial actions from the findings of IP and OP settled claims audits, and drive the implementation of these actions.
Reporting
Prepare reports to communicate outcomes of quality activities.
Monitor and share reports of TATs for all key claims processes.
Track claims paid in E02 vs D365, using exception reports to monitor paid, reversed, and cancelled claims.
Systems Enhancement
Continuously review the effectiveness of workflow systems and recommend enhancements.
Provide input on ML and core system enhancements to improve quality and output. Monitor risk management activities (GIA issues).
Prepare regular claims reports to management and advise the underwriter on relevant claims findings for medical risk review.
Perform root cause analysis and close out issues.
Enquiry Resolution & Leadership
Ensure timely completion of investigations/resolution arising from claims disputes in case management and claims teams.
Investigate suspected fraud issues, guide fraud reporting to GFS, and follow up to closure.
Coach, counsel, or train less-experienced staff; provide input in the performance management, goal setting, and review processes.
Skills and Competencies
Aligns Execution - Planning and prioritizing work to meet commitments aligned with organizational goals.
Manages Complexity - Making sense of complex, high volume and sometimes contradictory information to effectively solve problems.
Builds Effective Teams - Building strong-identity teams that apply their diverse skills and perspectives to achieve common goals.
Ensures Accountability - Holding self and others accountable for meeting commitments.
Business Insight - Applying knowledge of business and the marketplace to advance.
Strategic Vision - Seeing ahead to future possibilities and translating them into breakthrough strategies.
Drives Results - Consistently achieving results, even under tough circumstances.
Customer Focus - Provides cautious, timely and helpful service to encourage client loyalty.
Engages & Inspires - Creating a climate in which people are motivated to do their best to help the organization achieve its objectives.
Instils Trust - Gaining the confidence and trust of others through honesty, integrity, and authenticity.
Cultivates Innovation - Creating new and better ways for the organization to be successful.
Develops Talent – Developing internal talent.
Bio Statistics skills are key.
Knowledge & Experience
Minimum of 5 years of experience in clinical operations, claims processing, or a related field.
In-depth knowledge of Quality Assurance, claims processing, and regulatory requirements.
Qualifications
Bachelor's degree in Healthcare Administration, Nursing, or a related field.
Relevant certifications in healthcare management or clinical operations are preferred.
How to Apply 
