Job Purpose:
Managing Clinical processes and procedures through the use of effective techniques to achieve the objectives of cost control and operational efficiency.
Key Responsibilities
- Responsible for the development and implementation of clinical practice management aimed at providing.
leadership in the provision of healthcare to our members, as well as managing costs and Healthcare outcomes. - Develop and implement a Managed Care strategy aimed at coordinating medical care to achieve good patient experience, better treatment outcomes, and reduced healthcare costs.
- Manage contracts with service providers, including developing innovative reimbursement options and positioning Britam as a partner to the providers.
- Overseeing case management practices to ensure quality and sustainability.
- Provide leadership in developing metrics for measuring quality outcomes and obtain collaboration with service providers in meeting the set standards.
- Provide leadership in the utilization of clinical and claims data to develop innovative products and processes that provide a competitive advantage to Britam in health insurance services.
- Overall responsibility for managing chronic conditions and inpatient services cost outcomes through the wellness program.
- Guiding the business in compliance with health regulations relating to health insurance.
- Monitor, prevent, and control medical claims fraud by carrying out regular audits on the internal and external systems/ processes, as well as providers.
- Supervise, train, and mentor medical case management, Wellness Call Centre staff to achieve a high level of motivation and productivity by the team.
- Prepare regular reports to clients, management, and advise the medical underwriting section on relevant claims findings for medical risk review.
- Delegated Authority: As per the approved Delegated Authority Matrix.
Knowledge, experience and qualifications required
Knowledge, experience, and qualifications required
- Bachelor’s degree in a medical-related field
- Professional qualification in Insurance (ACII or IIK)
- 2 – 6 years’ experience in medical, with at least 2 years in a supervisory position.
- Experience in managing complex medical insurance operations (Claims, case management, and provider network)
