Michael Mwaniki

• Review and process claims submitted by policyholders or medical providers, ensuring accuracy and compliance with policy requirements.
• Assign medical codes to claims using coding systems such as ICD-10, CPT, or HCPCS.
• Analyze claims data to identify trends and patterns, detecting potential fraud, waste, and abuse.
• Research claims to ensure accuracy and completeness, contacting policyholders, medical providers, or other stakeholders as needed.
• Resolve issues related to claims, including denied claims or payment disputes, communicating with stakeholders to find a resolution.
• Ensure compliance with state and federal regulations and guidelines for processing claims.
• Verify eligibility and coverage for claims according to policy terms.
• Calculate payment amounts for claims based on policy coverage and coding.
• Use claims processing software and technology to manage and track claims.
• Conduct audits of claims data to verify accuracy and compliance.
• Provide support and guidance to policyholders, medical providers, or other stakeholders regarding claims-related issues.
• Continuously monitor and improve claims processing workflows and procedures to increase efficiency and accuracy.
• Collaborate with cross-functional teams to identify opportunities for process improvements and increase efficiency and accuracy in claims processing.
• Assist with training and development of new claims processing staff.
• Participate in quality assurance initiatives to ensure that all claims are processed accurately and efficiently.
• Prepare and submit reports on claims processing activity, including claims volume, turnaround time, and accuracy rates.
• Investigate and resolve coding issues related to claims processing, including coding discrepancies and coding errors.
• Provide excellent customer service to policyholders, medical providers, and other stakeholders throughout the claims process.

ACHIEVEMENTS

• Identified several providers with fraudulent patterns such as 'ghost claims' and manipulated invoices and reviewed for suspension from panel list through fraud, security, and investigation department based on claims analysis and client feedback
• Increased team productivity from 70% to 95% with measures such as improved claims flow, measurable individual targets derived from KPIs, effective delegation, automation, enhanced feedback system among other measures
• Actively participate in Changamka@ project aimed at identification and automation of mundane tasks with prompt and effective feedback and output through robotics and machine learning
• Reduced error rate from users from over 13% to below 5% by holding bi-weekly department trainings and personalized feedback to affected users.
• Training and leading a section of quality assurance department for >3 years and received back-to-back monthly performance-based awards
• Resolved communication gap that existed between different claims departments to improve information flow and streamline claims processing by enhancing interactions, promoting feedback and job shadowing opportunities.
• Closed old & dormant provider accounts through reconciliation and negotiations to ensure up-to-date status by reviewing on spreadsheets and holding meetings with concerned providers to discuss reviews and sign-off periods with disputed claims including top-tier providers such as Aga Khan Hospitals, Mater Misericordia, Nairobi Hospital, Karen Hospital AAR, etc.
• Spearheading enrolment of discounts and packages on Outpatient and Inpatient cases in mid & top-tier providers. This includes fixed-cost plans and inpatient and maternity packages that are based on provider business volumes and market trends
• Identification and resolution to system challenges through periodic systemic quality checks to monitor and address user and system challenges as per reporting schedule to pick patterns likely to cause long-term recurring challenges in productivity and claims adjudication if left unresolved
• Currently Serving as single point of contact for challenge resolution between disputed claims between claims department and providers to improve quality of service, prompt challenge resolution, and enhance customer satisfaction.
• Organizing continuing medical education (C.M.E.'s) for claims department with panel providers' specialists for training on new and upcoming medical practices

DEPARTMENT BASED COMPETENCIES:

CLAIMS QUALITY ASSURANCE:

• Providing leadership and direction to claims quality assurance analysts and other team members
• Cut down on backlog by developing and implementing strategies and innovations in systems and procedures to improve efficiency and effectiveness in claims processing such as automated processing and bulk review and processing for low-value claims vetted for biometrics.
• Increased team record savings to 10M shillings by recovering wrong bill payments by passing system credit notes.
• Reduce system gaps such as double discounts and user wrong claims adjudication patterns by scheduling and analyzing daily claims register report from BI that targets user and system gaps to address them on time before accumulation to recon stage
• Identified fraudulent provider billing patterns to identify suspicious transactions such as unwarranted medical charges, over-billing, and mismanagement activities
• Escalating suspected fraudulent cases to the Fraud, Security & Investigation Department for further action
• Being accountable for escalated claims and providing updates to the team manager by serving as a single point of contact for challenge resolution
• Organizing shadow visits to panel provider facilities to monitor progress and ensure quality and accuracy of claims services.
• Setting KPIs, goals, and objectives for the claims quality assurance team that align with company's objectives and helping team members to set targets and develop plans to achieve them while embracing a culture of employee engagement, and new ways of working with continuous improvement
• Manage team performance, including taking appropriate performance management actions and quarterly check-in conversations with team members
• Providing training and guidance to claims quality assurance analysts and other team members to ensure that they are following best practices and standards
• Collaborating with cross-functional teams to identify/address challenges that impact the quality and efficiency of claims processing and handling complex or high-risk claims
• Identifying and resolving disputes over claims in various stages of processing, such as declined, duplicate, or under investigation
• Maintaining up-to-date knowledge of industry standards, regulations, and best practices related to claims processing
• Mapping diagnoses in our Information Systems by the current International Classification of Diseases (ICD9, 10 & 11
• Assist in development and maintenance of metrics and reporting tools to measure the performance of claims' quality assurance process to ensure that process is effective and efficient while addressing weak points as identified
• Participating in audits and reviews of claims processing and handling to ensure compliance with internal policies and external regulations
• Managing budget and resources of the claims quality assurance team to ensure that it has the necessary resources to operate effectively
• Referring members with chronic illnesses to the wellness department based on claims activity and client requests

PAYMENTS & RECONCILIATION:

• Reconciling provider accounts by reviewing disputed medical claims and determining responsibility
• Holding in-person meetings with providers to discuss disputed claims, documenting feedback, and obtaining feedback for claim assessment and system user experience
• Seeking medical clarifications, such as medical reports and discharge summaries, for questionable cases
• Ensuring resubmitted documents are scanned and available for review and processing in the appropriate queues within agreed timelines
• Acting as a point of contact for panel providers with questions about the claims experience.

CLAIMS ANALYSIS:

• Reviewing and determining the validity of medical claims and ensuring compliance with claims adjudication processes for processing and payment
• Reviewing and adjusting preauthorization as needed based on eligible benefits and cover scope Having extensive knowledge of different claims policies, including individual, corporate, and SME schemes
• Reviewing and processing low and high-value claims in various categories, such as inpatient and outpatient, declines, duplicates, optical, dental, packages, and reimbursement claims
• Ensuring that correct details are captured in the system and reviewing bills to ensure the accuracy of client, provider, and invoice details
• Correcting erroneous payments by issuing credit notes and paying to the correct details as documented
• Reviewing reimbursement claims for processing according to reimbursement guidelines and adjudication processes
• Prioritizing workload by observing and meeting deadlines, using my initiative, suggesting recommendable approaches, and being responsible for set timelines for claims processing

PROVIDER RELATIONS & UNDERWRITING

• Analyzing claims data to suggest suitable discount and package plans for different providers based on business volumes, claims experience, and utilization patterns
• Monitoring onboarding providers to ensure compliance with panel policies
• Vetting and confirming the validity of services provided by service providers, including benefits covered, treatment given, adherence to panel rules, and cost of treatment
• Monitoring scheme utilization patterns and costs and taking or suggesting appropriate measures as needed
• Supporting medical underwriters by reviewing medical claims against underwriting decisions
• Ensuring that additions and deletions of members are accurately captured in the system and biometrics setups to avoid unwarranted claims
• Supporting medical underwriters by reviewing medical claims against underwriting decisions
• Participating in achieving the projected annual gross written premium and growth of the company's top-line and underwriting profit through claims control measures such as negotiating fair rates, discounts, and packages with panel providers to achieve desired budget, increase profit before tax and reduce cost ratios
• Accurately adjudicate claims, suspend fraudulent clients, and refer new business

• Created social media posts and fliers marketing which contributed to 22% increased product awareness in the year 2020
• Introduced 'courtesy calls' for our clients to check on and provide excellent customer service to all of our existing company clients
• Execute record filing system by scanning and digitizing physical copies to improve efficiency, organization and management
• Prior booking of meeting venues, organize weekly staff meetings and appointments ahead of time and sharing minutes on timely basis
• Answer multi-line phone systems, route calls, attend to mails, deliver messages to staff, respond to emails and receive visitors
• Create detailed expense reports based on monthly utilization
• Orient new employees on administrative procedures, company policies, and performance standards
• Restock office supplies and place purchase orders to maintain adequate stock levels
• Supervise other staff and plan responsibilities for each to ensure daily targets are met
• Liaise with management for due changes, implementation, and compliance with company policies
• Office contact for communications through phone calls, e-mail, letters walk-ins, and visit referral clients addressing client complaints and concerns
• Prepare monthly reports for presentations for transport, budget, payments and client activity
• Conducted onboarding to help new hires adjust to administrative and performance aspects of jobs

• Identified microorganisms present through PCR, Microscopy, Gram Staining, Sputum Test (ZN testing, TB Micro),CSF testing and analysis, Urinalysis, Stool Test (Cryptosporidium), Culture, Blood, and cultivated strains to support clinical diagnostics
• Reviewed microbiology samples received on a day and closed all at 100% by testing for disease markers and outlined findings in thorough reports for clinicians and clients.
• Managed stock levels to laboratory reagents, tools and other materials and ensured all testing equipment were 100% operational prior to day's activities.
• Assisted with safe transfusions by conducting tests and completing blood counts
• Analyzed bodily fluids with laboratory equipment and detected anomalies related to diseased states or acute injuries
• Maintained strict aseptic fields when collecting biological samples, minimizing staff and patient infection risks
• Assisted pathology team with skilled analyses by preparing tissue samples
• Set up, maintained, and verified sterility of lab equipment and tools
• Prepared variety of different written communications, reports, and documents to ensure smooth operations
• Proved successful working within tight deadlines and a fast-paced atmosphere
• Completed required tests on a timely basis to ensure compliance with client and employer expectations

• Increased sales by 10% by offering competitive information such as bid situations, pricing data, or bundling arrangements to establish negotiated pricing contracts for assigned products to potential clients.
• Logged 100% of daily orders and processed for laboratory, research, and diagnostic materials from clients into inventory management system.
• Liaised with distributors to ensure the availability of products in line with the laboratory channel
• Made the initiative to make regular visits to get feedback about company products and insight into competitors and ensure growth in product recommendation, listing, and stocking
• Actively listened to customers, handled concerns quickly and escalated major issues to supervisor
• Put extra hours on flexible hours across night, weekend and holiday shifts to close on weekly objectives.
• Utilized client rapport to obtain invites to market products to prospective and existing customers during workshops
• Recruited and managed existing customers within the company channel
• Planned and for Healthcare Professionals training events as per set plans and brand guidelines
• Attended medical congresses and actively engaged with Healthcare Professionals to transfer belief in the brand, influence perceptions, and build rapport.