Senior Case Management Officer– Wellness & Provider Relations
Job Purpose:
Supervising Health Care processes and procedures through the use of effective techniques to achieve the objectives of cost, Quality control and operational efficiency.
Key responsibilities:
- Ensure quality & affordable care to all admitted patients.
- Analysis and interpretation of admission, savings and average cost reports for effective cost control.
- Enrolment of members to CDM program and follow up.
- Work with the wellness team to ensure compliance.
- Verification and audit of outpatient and inpatient approval requests as per the claims manual and customer service charter manual to ensure compliance and mitigate risk
- Supervise; train and mentor case management officers to achieve a high level of motivation and productivity by the team.
- Negotiate professional fees and hospital charges including discounts to control expenditure.
- Hold regular business meetings with service providers to ensure compliance on contract terms, use of agreed systems and agreed tariffs.
- Monitor, prevent and control medical claims fraud by carrying out regular audits on the internal and external systems/ processes as well as providers.
- Prepare regular care reports to clients, management and advice medical underwriting section on relevant care findings for medical risk review.
- Delegated Authority: As per the approved Delegated Authority Matrix.
- Perform any other duties as may be assigned from time to time.
Knowledge, experience and qualifications required:
- Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
- Professional qualification in Insurance (ACII, FLMI or IIK) – added advantage.
- 6-8 years’ experience in medical claims handling two of which should be in a supervisory position in a busy insurance office.
- Knowledge of insurance concepts.
- Technical/ Functional competencies.
- Knowledge of insurance regulatory requirements.
- Knowledge of insurance products.
- Sales and marketing management skills.