Job Purpose:
Control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.
Key responsibilities:
- Ensure all received claims are vetted and released to finance on time (Credit and reimbursement claims).
- Set the appropriate parameters for each admission and claims for IP and OP (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 poly-pharmacy 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.
- 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 or Diploma in clinical medicine or Diploma in Pharmacy.
- Moderate understanding of insurance concepts.
- Professional qualification in FLMI, ACII and IIK.
- 5-8 years’ experience in case management two of which should be in a supervisory position.