National Health Insurance Management Authority (NHIMA)
The main role of the jobholder is to manage Health Care Providers claims and Finance/payment reconciliations by ensuring timely claim payments and reconciliations and identifying and correcting any discrepancies.
The role will also be responsible for receiving and admission of claims in the claims register and ensuring timely correspondence with Health Care Providers on any omissions that are picked before claims are admitted on the claims register.
1. Claim settlements and reconciliations (40% weight)
- Having knowledge and understanding of computer and the current insurance system in use, minimum requirement for a fully documented claim, claims protocols and procedures, and NHIMA Benefits and applied tariffs.
- To verify totals on the received invoices and inform Health Care Providers by e- mail/letter of any differences by matching statements from Health Care Providers with batches on the claims register and physical claims
- Reconcile balances between Health Care Providers and NHIMA and maintain files for each Health Care Provider for returned bills to have quick and efficient access to HCP Queries
- To reconcile all payments with Health Care Providers within 90 days of receiving settlement cheque/transfer advice; Health Care Providers are required to re-submit returned/suspended claims requiring additional/missing information within 15 days of advice and the job holder will be required to ensure that this is adhered to.
- Follow up reconciliation statements submitted on a month-by-month basis
- Prepare updated reconciliation statements for HCP Accounts on a weekly basis and submit Weekly, monthly, quarterly and adhoc reports to Supervisor.
- Preparation of Individual HCP Quarterly Reconciliation statements and submit to HCP after verification with Supervisor, every quarter and reconcile accounts within 15 days of submission to HCP.
- Sign off accounts once reconciliation is agreed and completed and maintain report on
Health Care Providers’ Sign offs for due reference as required
2. Health Care Provider Customer Care & Preliminary Claims Preassessment (60% weight)
- Receive claims from Health Care Providers and conduct quality check/preliminary claims assessment for obvious omissions immediately on submission for physically delivered claims and within 5 days for couriered and SFTP uploaded claims
- Maintain emerging issues tracker to be shared as part of weekly reports for due intervention
- Ensure any picked submission omissions are communicated to Health Care Providers within 10 days from received date
- Admit all qualifying claims in the claims register immediately on receipt
- Maintain good business relationship with Health Care Providers and conduct Health Care Provider sensitisation on NHIMA Benefits, Tariffs, and importance of properly filled in claim forms
- Post adjudication and post payment, actively timely engage Health Care Providers on claims submission omissions, incomplete and rejected claims, to avoid unnecessary disputes and disruptions in service provision due to non-payment of such claims.
- Maintain regular contact with Health Care Providers and any unpaid bills should be advised to the Health Care providers within 15 days after payment remittance notification by Finance.
- Participate in any other claims process roles as demand arises and as guided by the Supervisor
Knowledge, Skills, Qualifications and Experience
- Grade twelve (12) School certificate with 5 ‘O’ levels with credit or better including Mathematics and English Language.
- First Degree in any field.
- Certificate or Diploma in Health Insurance, Clinical Health related field, Compensation fund or social security will be an added advantage.
- 2-3 years in a similar role,
Competencies required for this Role
- Excellent knowledge of marketing and customer service,
- Good oral and written communication skills,
- Must be computer literate with MS Office applications skills,
- Attention to detail, and Excellent analytical skills
To apply for this job please visit careers.nhima.co.zm.