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.