National Health Insurance Management Authority (NHIMA)
Job Title: Provider Reconciliation Officer
The main role of the job holder will be day to day management of claims from health care providers, ensuring that claims are paid timeously and in accurate amounts. It will also be responsible for ensuring the submitted claims are paid out within the agreed service level agreements by ensuring timely submission to subsequent workflows and tracking the turnaround times within those workflows.
CLAIMS TRACKING & PRE-ASSESMENT (60% WEIGHT)
- Conduct first line quality assurance check on the submitted claims to ensure the claims meet NHIMA protocols
- Conduct first line pre- assessment of submitted claims batches by verifying totals on the actual against accompanying invoices/statements
- Timeously register new claim submissions from accredited health care providers.
- Track claims through the various subsequent workflows.
- Measure performance of the various workflow turnaround times against agreed service level agreements
CLAIM SETTLEMENTS AND RECONCILIATIONS (30% WEIGHT)
- Timely inform Health Care Providers of any variations between submitted claims and covering statements
- Maintain files for each Health Care Provider for returned/suspended bills to have quick and efficient access to HCP Queries
- Preparation of Post adjudication claims assessment summaries
- Preparation of claims payment requisition schedules
- Participate in adhoc & quarterly claims & Finance reconciliation
- Prepare Weekly/Monthly & adhoc claims status reports on submissions, adjudication, payment and capture any outliers to help timely intervention on any identified gaps
- Manage filing of various claims records for easy reference as required
- Attend to audit queries
HEALTH CARE PROVIDER & CUSTOMER CARE RELATIONS (10% WEIGHT)
- Resolve all queries from members and Health Care Providers in line with internal processes and turn around targets
- To escalate all other matters as may be pertinent in line with the internal escalation processes
- To perform any other role as may be assigned from time
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.
Competencies required for this Role
- 3-5 years in a similar role,
- Must have a valid class ‘B’ driving license,
- 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
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To apply for this job please visit careers.nhima.co.zm.