Quality Assurance Nurse at Stresert Services Limited

Responsibilities

• Attend to calls and resolve queries relating to the specific units or groups within the organization (route queries to appropriate departments for professional and prompt resolution in complex cases).
• Efficiently utilize the official mobile phone, internet modem and all other work tools for prompt issuance of pre-authorization code to enrollees.
• Attend to and resolve all enrollees’ enquires and ensure that all complaints are promptly resolved on first call resolution, or immediately escalated to the appropriate group or unit.
• Meticulously log all for management analysis and documentation for all relevant stakeholders.
• Follow-up on specific cases as assigned by the line manager for measurable outcomes and stakeholders’ satisfaction.
• Actively and proactively engage in the vetting of bills from the organization’s network of facilities providing secondary/tertiary healthcare services on the public sector social health insurance program
• Benchmark all received claims with the pre-authorized codes given by call center as any service provided by any facility without pre-authorized code is considered null and void.
• Review all the received bills and possibly contact the enrollees for authorization of services provided.
• Promptly get back to all facilities informing them of the receipt of their bills and clarifying any issues with the bills to eliminate any form of ambiguity.
• Ensure prompt conflict/ grievance resolution with providers through a standard conflict resolution working tool to be developed and approved by the Management.
• Investigate and report any incident of abuse, neglect or maltreatment of enrollees immediately to the Management for appropriate actions to be taken.
• Follow up on enrollees on admission in order to evaluate and document their progress and possibly assist the care team with developing and accessing health interventions.
• You are expected to regularly ensure the satisfaction of all our enrollees, as you are expected to regularly troubleshoot and promptly attend to all their enquires and needs, most especially cascading of their chosen facilities on a monthly basis and the production enrollees’ identification cards
• Forward payment advice to all facilities whose bills were settled on a regular basis to completely eliminate the confusion that emanates from lack of settlement of bills by the HMO.
• Actively participate in the inspection and re-inspection of health care facilities to ensure the sustainability of identified set of standards.
• Actively engage in the proper and regular sensitization of all existing enrollees for good understanding of the workings of health insurance.
• Participate in case management through scheduled and unscheduled visitation to enrollees on admission.
• Ensure that received bills are promptly vetted and passed to the appropriated authority for necessary action as pilling up of bills is a grievous offence in this company.

Requirements/Skills

• Must be a registered nurse.
• Min of 5 years’ experience as a Quality Assurance Nurse.
• Ability to work harmoniously with others.
• Customer management
• Ownership mindset
• Intrapreneurial
• Teamwork
• Collaboration skills
• Good communicator
• Solution-provider
• Analytical in thinking and approach