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
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 environ
- 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
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
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
