Case Management Officer at Britam

Job Description

Job Purpose: 

Reporting to the Manager Clinicals, the role holder will be responsible for control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.

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. 
• Ensure that medical scheme members are attended to round the clock with support from 24 hour call centre. 
• 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. 
• Delegated Authority:  As per the approved Delegated Authority Matrix.
• Prepare periodic reports for management on medical claims. 
• Ensure claims are processed within the stipulated time.  
• 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. 
• Understanding of insurance concepts. 
• Professional qualification in FLMI, ACII and IIK would be an added advantage.
• 3-4 years’ experience in case management.