Job Purpose:
Reporting to the Assistant Manager Case & Provider Management, 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.
- 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.
- Progress in Professional qualification in Insurance (ACII, FLMI or IIK).
- 3-6 years’ experience in case management.
- 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.
