Old Mutual Kenya Quality Assurance Manager - Health Jobs
Key Tasks and Responsibilities
Conduct quality audits of claims, focusing on high‑value, repeated visits, and duplicate claims.
Identify providers with billing irregularities or suspected fraud and engage them regularly.
Review claims relating to benefit excesses and assign liability appropriately.
Track admissions, checking for exaggerated bills, unnecessary admissions, or overstays.
Review integration exception reports between E02 and D365.
Conduct trending analysis, identify leakage, and prepare objective reports.
Enforce claims cost controls (copayments, discounts, restrictions, waiting periods).
Monitor compliance with SOPs for claims, case, and provider management.
Manage reserve philosophy for admissions and approvals.
Review inpatient bills for scheduled cases monthly.
Review reimbursement reports and conduct impromptu visits.
Contribute to competency‑based training and identify knowledge gaps.
Review policy terms with retention team to identify gaps.
Recommend and drive remedial actions from audit findings.
Prepare reports to communicate quality outcomes.
Monitor turnaround times (TATs) for claims processes.
Track claims paid in E02 vs D365 using exception reports.
Continuously review workflow systems and recommend enhancements.
Provide input on ML and core system enhancements.
Prepare regular claims reports and advise underwriters on medical risk.
Resolve client enquiries and disputes promptly.
Investigate suspected fraud and guide reporting to GFS.
Coach, counsel, and train staff; contribute to performance management.
Skills and Competencies
Aligns Execution – Plans and prioritizes work to meet commitments.
Manages Complexity – Makes sense of complex, high‑volume information.
Builds Effective Teams
– Applies diverse skills to achieve goals.
Ensures Accountability – Holds self and others accountable.
Business Insight – Applies market knowledge to advance strategy.
Strategic Vision – Translates future possibilities into strategies.
Drives Results – Achieves outcomes under tough circumstances.
Customer Focus – Provides timely, helpful service to encourage loyalty.
Engages & Inspires – Motivates people to achieve objectives.
Instils Trust – Gains confidence through honesty and integrity.
Cultivates Innovation – Creates new ways for success.
Develops Talent – Builds team capability.
Biostatistics skills are key.
Knowledge & Experience
Minimum 5 years’ experience in clinical operations, claims processing, or related field.
In‑depth knowledge of quality assurance, claims processing, and regulatory requirements.
Qualifications
Bachelor’s degree in Healthcare Administration, Nursing, or related field.
Relevant certifications in healthcare management or clinical operations preferred.
How to Apply
For more information and job application details, see; Old Mutual Kenya Quality Assurance Manager - Health Jobs
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