Job Description

To control and manage medical benefit utilization through preauthorization and case management activities and ensure quality, appropriate cost-effective care and good customer service.

 1. KEY TASKS AND RESPONSIBILITIES

• Pre-authorize scheduled and non-scheduled admissions within the set guidelines.
• Negotiate/discuss professional fees as appropriate for each admission.
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
• Visit all admitted clients within Nairobi region and its environs
• Liaise with Doctors on the day-to-day management of patients and obtain medical reports/ expected length of stay where indicated.
• Ensure smooth discharge process and co-ordinate any necessary post-hospitalization/ step down facility care.
• Revise reserves after discharge of member.
• Collect feedback from admitted clients on quality and scope of service by the service provider.
• Assist in carrying out verification and medical audit of claims/invoices before settlement.
• Develop and maintain monthly database on admissions, large claims and extended length of stay.
• Respond to queries from clients, intermediaries and service providers.
• Liaise with other medical underwriter for purposes of market surveys and development of new controls, standards and products.
• Any other duty assigned by management.

2. SKILLS AND COMPETENCIES

• Excellent communication and negotiation skills.
• Excellent public relations and interpersonal relationship skills.
• Extensive networking with SP and other medical insurers.
• Excellent analytical and monitoring skills
• Good IT skills in database management and office systems.
• Good decision making in benefit utilization management.
• High levels of integrity and honesty.

3. QUALIFICATIONS, KNOWLEDGE & EXPERIENCE

• Diploma or Degree in Nursing
• Diploma in Insurance/ COP
• Degree in Health systems Management/ Business management
• 3 years’ experience in clinical setting +2 years in insurance set up.