Esther Musili

I am an energetic, enthusiastic Kenyan female with diploma in Clinical Medicine and Surgery and registered by the Kenyan Clinical officer’s council. I have over 1 and a half years of clinical practice and over 4 years in medical insurance and customer service industry.

I started in the medical facility as a Clinician/Physician Assistant and ended up in Healthcare Insurance industry. With this, flexibility has never been a challenge even in my previous roles in different organizations.

Amongst my personal traits is teamwork, interpersonal skills, coupled with honesty and integrity. I am confident you will find I possess the skills, dedication and personal characteristics to make a positive contribution to the staff as a medical claims adjuster and a vital part of your organization.

Below are my job description

• Processing and approval of patient’s preauthorization by reviewing patient's history and records and assessing pre authorizations to ensure details are captured correctly.
• Assessing whether patient's treatment and prescription correlates with the diagnosis and is in adherence to scheme rules and with reasonable pricing.
• Approval of member claim code generation.
• Confirming membership validity and benefits before pre authorization processing.
• Negotiation of medical fees and costs of services for the patients with the Service Providers.
• Managing the daily running of the call center related issues by responding to emails, calls and medical related questions and inquiries.
• Processing of medical claims for payment and identifying fraudulent.
• Liaising with supervisors, team leaders, managers and third parties to gain information and resolve issues related to medical claims.
• Liaising with service providers and referring of patients for specialized care/treatment.
• Receiving emergency calls, assessing the client’s condition, requesting for an ambulance dispatch for evacuation, informing the receiving facility and following up on the case until the client gets handed over.
• Identifying fraudulent pre authorizations to reduce costs.
• Providing cover for colleagues in their absence, ensuring that the handling of pre authorizations is kept up to date.
• Scheme implementation to enable monitoring of scheme success as well as give insight into the challenges and share lessons learnt with other team members.
• Taking ownership of complex Medica cases, handling them accurately and with personal attention that is required.
• Keeping up to date knowledge with respect to the Medical information necessary for handling Medical claims.
• Evaluate claims submitted from service providers for reimbursement and make decisions regarding reasonableness of the payments.