Care Officer – Call Centre

Customer Service Representative - Medical Insurance

Job Summary

This position is responsible for providing efficient and effective customer service to all GA Insurance Limited’s internal and external customers with utmost consistency and quality.

Duties and Responsibilities

Core Customer Service Duties

• Attend to client general queries, including answering calls from customers regarding membership eligibility, claim status, benefit information, and claim payments or denials.
• Inform clients by explaining procedures, answering questions, and providing needed information.
• Ensure medical pre-authorizations, undertakings, admissions, discharges, and declines are issued in compliance with policy provisions and authority limits.
• Resolve escalated issues via emails or calls within stipulated timelines to ensure customer satisfaction and loyalty.
• Liaise with doctors, brokers, and clients via phone or email for patient admissions.
• Advise members on how to best utilize their benefits by recommending cheaper facilities and options (e.g., maternity packages, chronic management facilities).
• Log claims on the system in a timely manner.
• Monitor turnaround time on email responses by logging the time emails are received on the care team email address.
• Liaise with underwriters for missing scheme membership, benefit, member, or dependent details in the system and scope of cover.
• Properly hand over admissions and discharges above the authorized limit to the care nurse or senior care officer.

Complaints Management and Audit Compliance

• Observe guided information to clients and relevant authorized parties in compliance with the Data Protection Act.
• Receive customer complaints or queries and document them.
• Follow up on complaints and ensure they are resolved within set service level agreements.
• Communicate feedback to clients.
• Participate in identifying service gaps and provide feedback on necessary corrective measures.
• Ensure all issues are assigned to relevant parties and closed.
• Ensure follow-through of set-out policies and procedures.

Academic and Professional Qualifications

• Bachelor’s Degree or Diploma in Nursing (KRCHN), Clinical Medicine & Surgery, Health Management, or a related field.
• Possession of Health System Management qualifications is an added advantage.
• Kenya Registered Nurse / Kenya Registered Community Health Nurse.
• Additional training in customer service is an added advantage.

Experience

At least 2 years of experience in a similar role and industry.

Technical Competencies

• Proficiency in MS Office package.
• Conversant with medical terminology to explain benefits and claims clearly.
• Knowledge of insurance industry and concepts.
• Knowledge of insurance regulatory requirements.
• Working knowledge of customer and relationship management.
• Demonstrated experience in customer management and query resolution within care management.

Behavioural Competencies

• Demonstrated empathy and understanding in handling client concerns.
• Actively listening to accurately identify and address customer needs.
• Ability to multitask interactions and tasks efficiently.
• Strong customer service orientation.
• Strong analytical and problem-solving skills.
• Results driven and action oriented.
• Collaborative team player.
• Strong attention to detail.
• Agile mindset with demonstrated ability to manage tasks with competing deadlines.
• High degree of emotional intelligence, integrity, trust, and dependability.
• Ability to work independently as well as part of a team.