Claims Management Officer I at The Social Health Authority (SHA)

The Social Health Authority (SHA) is a State Corporation established under the Social Health Insurance Act, 2023 and mandated to provide financial risk protection for Kenyan residents by facilitating equitable access to quality healthcare. SHA is responsible for administering the Social Health Insurance Fund, Primary Healthcare Fund, and Emergency, Chronic, ...

 

Claims Management Officer I

  • Job TypeFull Time
  • QualificationBA/BSc/HND
  • Experience
  • LocationNairobi
  • Job FieldInsurance 

Qualifications, Skills and Experience Required:

For appointment to this grade, an officer must have:

Entry Grade for Claims Management-Medical Review 

  • Bachelor’s Degree in Medicine and Surgery from a recognized institution; 
  • Membership to the relevant professional body and in good standing; 
  • A valid practicing license; 
  • Proficiency in computer applications. and 
  • Shown merit and ability as reflected in work performance and results.

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 (Medical Review) 
  • Claims Management 
  • County Coordination (Quality Assurance and Surveillance) 

Claims Management (Medical Review) 

This is the entry and training grade for officers in Claims Management-Medical Review. An officer at this level will work under the guidance of a senior officer. 

Key Responsibilities

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

Claims Management 

Key Responsibilities

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

Quality Assurance and Surveillance 

Key Responsibilities 

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

Check how your CV aligns with this job

Method of Application

Interested and qualified? Go to The Social Health Authority (SHA) on recruitment.sha.go.ke to apply

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