Job Purpose:

To effectively process medical claims by verifying and updating information about submitted claims and reviewing the work processes required to determine reimbursement. This includes verifying submitted claims, assessing reimbursement policies, performing reconciliation with claims estimates, and conducting payment negotiations and providing support on the process of medical claims as well as support of all retention strategies.

Key responsibilities:

• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
• Interact with clients and service providers to ensure that the care is given within policy guidelines.
• Review medical reports and claims for compliance with set guidelines.
• Liaise with underwriters on scope of cover for the various schemes.
• Poly-Pharmacy – discourage polypharmacy by diligent challenging of prescriptions and suggesting better alternatives.
• Generic substitution – Encourage use of generics where indicated as a method of reducing the organizations pharmaceutical expenditure.
• Analyze proposed risks and make decisions to accept or reject.
• Determine the rates and terms to charge.
• Ensure risk survey recommendations are communicated in time and follow up implementation.
• Ensure underwriters comply to the company credit policy.
• Build and manage relationships with brokers, agents, and other intermediaries.
• Monitor market trends and competitor activities to stay informed about industry developments and stay updated on changes in laws and regulations that may affect client retention efforts.
• Work closely with sales, marketing, actuarial, to align retention strategies with business goals.
• Proactively manage the policy renewal process to ensure timely renewals and minimize lapses in coverage.
• Review and negotiate renewal terms and conditions with clients to retain their business.
• Develop and implement strategies to improve client retention rates.
• Prepare periodic reports for management on medical claims.
• Ensure claims are processed within the stipulated time.
• Delegated Authority: As per the approved Delegated Authority Matrix.

Key Performance Measures:

As described in your Personal Score Card.

Knowledge, experience and qualifications required

• Diploma/Degree in Nursing/ Diploma in clinical medicine/ Diploma in Pharmacy/ Bachelor’s degree (insurance option preferred).
• Progress in Professional qualification in Insurance (ACII, FLMI or IIK).
• 1-3 years’ experience in Health.
• Proven experience in managing and nurturing client relationships.
• Track record of achieving client satisfaction and retention targets.

Technical/ Functional competencies:

• Knowledge of insurance regulatory requirements.
• Knowledge of insurance products.
• Sales and marketing management skills.