Health Service / Quality Assurance OfficerMarkfema

• Shall be ready to work hard and push the limits in ensuring claims vetting and fluent management process.
• Shall be responsible for vetting all claims submitted by our Providers to ensure they are error and fraud-free
• They will manage claims payment and be involved in the resolution of medical cases requiring special attention.

Key Responsibilities

• Examine Healthcare Providers’ Claims using the Tariff agreement to determine authenticity and payment.
• Decline fraudulent Healthcare Providers’ Claims and state causative reasons.
• Forward approved Claims to Team Lead for review and final approval.
• Investigate complicated Claims and escalate to the Team lead, if necessary.
• Carry out a physical inspection at the assigned provider’s office using the checklist.
• Investigate complicated claims by checking the case folder and speaking to the Enrollee and the doctor.
• Update Providers’ dashboard, and implement resolutions.

Minimum Qualifications

• Minimum of a Bachelor of Medicine and Bachelor of Surgery (MBBS).
• 3 years of work experience.
• Additional post-graduate qualifications will be an advantage
• Previous relevant work experience in a similar role will be an added advantage
• Excellent Numeracy, Analytical and Problem-solving skills.
• Strong ability to make judgments on medical/ surgical cases in relation to benefits listed on enrollee’s benefits.
• Ability to make a professional judgment on coverage and non-coverage of care requests per time, based on the enrollee’s benefits table.
• Candidate must have strong computer skills.