Old Mutual Kenya is based in Nairobi and 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 which are: Respect, Integrity, Accountability and Pushing beyond boundaries.

KEY TASKS AND RESPONSIBILITIES

Claims processing

Clinical Review of Claims:

• Assess all inpatient and outpatient claims for clinical accuracy and relevance.
• Verify that diagnosis, treatment, procedures, and drugs align with standard clinical guidelines and patient history.
• Identify any overutilization, unnecessary procedures, or inconsistencies.

Policy and Benefit Verification:

• Cross-check claims against policy limits, exclusions, and benefits.
• Ensure the claim falls within the member’s coverage scope and authorization rules.

Fraud, Abuse and Wastage Detection:

• Investigate claims for potential fraud, abuse, or misrepresentation by providers or members.
• Flag and escalate suspicious or irregular claims for further review or audit.

Medical Coding Validation:

• Validate accuracy of diagnosis (ICD-10), procedure (CPT), and drug codes (ATC).
• Ensure proper coding to facilitate accurate claim adjudication and payment.

Claims Documentation Review:

• Review supporting documents (discharge summaries, lab reports, prescriptions) to ensure they justify the services billed.
• Request clarifications or additional documentation about where gaps exist.

Pre-authorization and Approval Compliance:

• Confirm that claims submitted post-treatment had prior authorization or approval where required.
• Reject or defer claims lacking appropriate pre-approval.

Turnaround Time (TAT) Management:

• Ensure vetted claims are processed within the standard timeframes to avoid delays in payment.
• Adhere to customer service charter manual to ensure compliance to agreed turnaround time.

Provider Communication:

• Liaise with healthcare providers for clarification, justifications, or amendments to submitted claims.
• Communicate and liaise with medical service providers on resolution of disputed claims and address the root cause
• Hold regular business meetings with service providers to ensure compliance on systems such smart card system and agreed tariffs.

Internal Collaboration:

• Work closely with claims capture, reconciliation, finance, underwriting and case management teams to ensure accurate and end-to-end claim handling.

External Collaboration

• Evaluate preliminary claim information and revert to broker or insured for more information where necessary to ensure that the correct information is documented for ease in processing of member reimbursement claims
• Respond to client enquiries within 24hrs of enquiry.

Reporting and Trend Analysis.

• Use of data analytics to review cost and quality of service at medical service providers
• Review claims reports and provide recommendations to retention, case, and provider relations teams on trends noted.
• Provide feedback on recurring errors or patterns noted during vetting.

Training and Feedback

• Collaborating with trainers to ensure the feedback loop from the claims audit is complete.
• Develop and implement quality control measures to prevent future errors and improve efficiency in claims processing
• Stay up to date with changes in healthcare laws, regulations, and best practices related to claims management.

Monitor and support risk management activities:

• Prompt reporting of any identified risks during claims processing for mitigation.
• Ensure all audit items are closed in your respective area.

Systems Enhancement

• Continuously review the effectiveness of workflow systems and recommend enhancements.
• Provide correct input on ML and core system enhancements to improve quality and output.

Skills and Competencies

• Aligns Execution - Planning and prioritizing work to meet commitments aligned with organizational goals.
• Proficiency with claims management software and data analysis tools
• Motivated team player who is detail oriented.
• Excellent communication skills, both written and verbal

KNOWLEDGE & EXPERIENCE

• 1-3 years’ experience Medical claims/Case management In-depth knowledge of healthcare operations claims processing, and regulatory requirements.
• Experience working in the Insurance industry preferred.
• Knowledge in data analysis and statistics are desirable.

QUALIFICATIONS

• Bachelor of Science in Nursing (BScN) or Diploma in Nursing (KRCHN) or Clinical Medicine or a related field

• Assess all inpatient and outpatient claims for clinical accuracy and relevance.
• Verify that diagnosis, treatment, procedures, and drugs align with standard clinical guidelines and patient history.
• Identify any overutilization, unnecessary procedures, or inconsistencies.
• Cross-check claims against policy limits, exclusions, and benefits.
• Ensure the claim falls within the member’s coverage scope and authorization rules.
• Investigate claims for potential fraud, abuse, or misrepresentation by providers or members.
• Flag and escalate suspicious or irregular claims for further review or audit.
• Validate accuracy of diagnosis (ICD-10), procedure (CPT), and drug codes (ATC).
• Ensure proper coding to facilitate accurate claim adjudication and payment.
• Review supporting documents (discharge summaries, lab reports, prescriptions) to ensure they justify the services billed.
• Request clarifications or additional documentation about where gaps exist.
• Confirm that claims submitted post-treatment had prior authorization or approval where required.
• Reject or defer claims lacking appropriate pre-approval.
• Ensure vetted claims are processed within the standard timeframes to avoid delays in payment.
• Adhere to customer service charter manual to ensure compliance to agreed turnaround time.
• Liaise with healthcare providers for clarification, justifications, or amendments to submitted claims.
• Communicate and liaise with medical service providers on resolution of disputed claims and address the root cause
• Hold regular business meetings with service providers to ensure compliance on systems such smart card system and agreed tariffs.
• Work closely with claims capture, reconciliation, finance, underwriting and case management teams to ensure accurate and end-to-end claim handling.
• Evaluate preliminary claim information and revert to broker or insured for more information where necessary to ensure that the correct information is documented for ease in processing of member reimbursement claims
• Respond to client enquiries within 24hrs of enquiry.
• Use of data analytics to review cost and quality of service at medical service providers
• Review claims reports and provide recommendations to retention, case, and provider relations teams on trends noted.
• Provide feedback on recurring errors or patterns noted during vetting.
• Collaborating with trainers to ensure the feedback loop from the claims audit is complete.
• Develop and implement quality control measures to prevent future errors and improve efficiency in claims processing
• Stay up to date with changes in healthcare laws, regulations, and best practices related to claims management.
• Prompt reporting of any identified risks during claims processing for mitigation.
• Ensure all audit items are closed in your respective area.
• Continuously review the effectiveness of workflow systems and recommend enhancements.
• Provide correct input on ML and core system enhancements to improve quality and output.

• Aligns Execution - Planning and prioritizing work to meet commitments aligned with organizational goals.
• Proficiency with claims management software and data analysis tools
• Motivated team player who is detail oriented.
• Excellent communication skills, both written and verbal

• Bachelor of Science in Nursing (BScN) or Diploma in Nursing (KRCHN) or Clinical Medicine or a related field