Care & Claims Manager – Medical

Reporting to the Chief Executive Officer, the role is responsible for both claims and care functions within the medical department to ensure efficiency in claims and care management as well as adherence to set guidelines, regulatory requirement and best medical practice.

Key Responsibilities

• Claims Processing & Assessment
• Monitor and report on cost containments measures/targets set within the claims vetting /audit section.
• Process claims at audit/vetting level to ensure payments are done within SLAs.
• Coordinate with claims registration and provider relations team to ensure payments to providers have been settled within the acceptable timelines as per SLAs.
• Coordinate with provider management team and claims registration section to ensure desired provider reconciliations and sign offs are achieved.
• Analyze and report on claims trends to identify high cost providers and non-adherence to contractual rates; together with provider relations team engage providers to ensure desired trends are achieved
• Timely resolution and escalation of complex claims to senior Manager.
• Approval of member reimbursement claims for processing.
• Monitoring and evaluation of claims auto vetting functionality for efficiency
• Monitor and report claims levels to ensure acceptable claims aging score
• Responsible for advising service providers on exclusions and non-payments
• Review vetted claims to ensure assurance and alignment with insurance cover terms.
• Review service provider lists to align with market rates
• Coordinate hospitalization visits for all active members.
• Ensure timely response to all pre-authorization requests received by various service providers.
• Identify opportunities to improve system processes relating to claims vetting and payment processing
• Participate in loss ratio meetings to review cost drivers and suggest/monitor appropriate interventions
• Identify clients suitable for Chronic Disease Management for follow up
• Submit required regulatory reports on a monthly basis.
• Risk assessment and compliance
• Monitor adherence to internal processes and procedures as per the relevant manuals; comply with all relevant external legislation and regulations with regard to claims processing.
• Ensure all risk management requirements within claims vetting & audit are addressed and where necessary escalated through the available defined channels
• Identify/investigate on suspicious and fraudulent claims for appropriate action
• Analyze and report on auto vetted claims for quality assurance and correct ICD coding use.
• Participate in internal and external audit reviews and responses
• Responsible for data confidentiality in handling medical claims
• Monitor core system user rights access
• Customer experience
• Responsible for communication of inadmissible reimbursement claims on clinical matters to key stakeholders.
• In collaboration with provider management, case management and risk underwriting teams resolve/escalate complex case issues.
• Participate in ex gratia committee approval to support deserving cases
• Ensure timely response to all customer service calls received
• Participate in provider empanelment to support provider accessibility
• Communicate with stakeholders on claims related issues
• Relationship management with all licenced intermediaries
• Coordinate health and wellness camps whenever required.
• Performance management
• Set targets for claims vetting and audit to align with business growth.
• Monitor and report claims vetting and audit daily output targets are achieved and overall claims levels are maintained within acceptable ranges.
• Carry out performance appraisal
• Training, coaching and mentoring of staff
• Resource allocation, staff skills mix and leave approval
• Management of employee leave entitlement
• Audit & Compliance
• Monitor adherence to internal processes and procedures as per the relevant manuals; comply with all relevant external legislation and regulations with regard to care processes.
• Ensure all risk management requirements within care and call Centre are addressed and where necessary escalated through the available defined channels
• Participate in internal and external audit reviews and responses
• Any other duties that may be assigned from time to time.
• Who We’re Looking For

Qualifications

• Bachelor’s Degree in relevant field
• Uganda Registered Nursing (URN)
• Diploma in Insurance is an added advantage.
• Minimum of 4-years’ experience
• Key competencies
• Organized, detail-oriented, and able to work under tight timelines.
• Committed to professional growth and continuous learning.
• Good collaborator with good communication skills.
• Why Join us?
• Join CIC Insurance Group as a Care & Claims Manager – Medical and play a strategic role in driving excellence in medical claims and care management. You will lead initiatives focused on claims efficiency, cost containment, clinical quality, regulatory compliance and exceptional customer experience. Working with diverse stakeholders and leading a dedicated team, you will influence claims performance, strengthen healthcare provider partnerships and drive continuous improvement in medical service delivery. CIC offers a dynamic and collaborative environment where you can leverage your expertise, demonstrate leadership and contribute to delivering sustainable, innovative and customer-focused medical insurance solutions.
• Monitor and report on cost containments measures/targets set within the claims vetting /audit section.
• Process claims at audit/vetting level to ensure payments are done within SLAs.
• Coordinate with claims registration and provider relations team to ensure payments to providers have been settled within the acceptable timelines as per SLAs.
• Coordinate with provider management team and claims registration section to ensure desired provider reconciliations and sign offs are achieved.
• Analyze and report on claims trends to identify high cost providers and non-adherence to contractual rates; together with provider relations team engage providers to ensure desired trends are achieved
• Timely resolution and escalation of complex claims to senior Manager.
• Approval of member reimbursement claims for processing.
• Monitoring and evaluation of claims auto vetting functionality for efficiency
• Monitor and report claims levels to ensure acceptable claims aging score
• Responsible for advising service providers on exclusions and non-payments
• Review vetted claims to ensure assurance and alignment with insurance cover terms.
• Review service provider lists to align with market rates
• Coordinate hospitalization visits for all active members.
• Ensure timely response to all pre-authorization requests received by various service providers.
• Identify opportunities to improve system processes relating to claims vetting and payment processing
• Participate in loss ratio meetings to review cost drivers and suggest/monitor appropriate interventions
• Identify clients suitable for Chronic Disease Management for follow up
• Submit required regulatory reports on a monthly basis.
• Monitor adherence to internal processes and procedures as per the relevant manuals; comply with all relevant external legislation and regulations with regard to claims processing.
• Ensure all risk management requirements within claims vetting & audit are addressed and where necessary escalated through the available defined channels
• Identify/investigate on suspicious and fraudulent claims for appropriate action
• Analyze and report on auto vetted claims for quality assurance and correct ICD coding use.
• Participate in internal and external audit reviews and responses
• Responsible for data confidentiality in handling medical claims
• Monitor core system user rights access
• Responsible for communication of inadmissible reimbursement claims on clinical matters to key stakeholders.
• In collaboration with provider management, case management and risk underwriting teams resolve/escalate complex case issues.
• Participate in ex gratia committee approval to support deserving cases
• Ensure timely response to all customer service calls received
• Participate in provider empanelment to support provider accessibility
• Communicate with stakeholders on claims related issues
• Relationship management with all licenced intermediaries
• Coordinate health and wellness camps whenever required.
• Set targets for claims vetting and audit to align with business growth.
• Monitor and report claims vetting and audit daily output targets are achieved and overall claims levels are maintained within acceptable ranges.
• Carry out performance appraisal
• Training, coaching and mentoring of staff
• Resource allocation, staff skills mix and leave approval
• Management of employee leave entitlement
• Monitor adherence to internal processes and procedures as per the relevant manuals; comply with all relevant external legislation and regulations with regard to care processes.
• Ensure all risk management requirements within care and call Centre are addressed and where necessary escalated through the available defined channels
• Participate in internal and external audit reviews and responses
• Any other duties that may be assigned from time to time.
• Organized
• detail-oriented
• able to work under tight timelines
• Committed to professional growth
• continuous learning
• Good collaborator
• good communication skills
• Bachelor’s Degree in relevant field
• Uganda Registered Nursing (URN)
• Diploma in Insurance is an added advantage.
• bachelor degree
• 48
• JOB-6af46e758e135