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.