Job Purpose:

• Controlling and Managing policies through case management to ensure quality and cost effective healthcare, client service, provider management, processing provider claims and clients for payment.

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.
• Process claims and claims vetting.
• 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.
• Discourage poly-pharmacy by diligently challenging of prescriptions and suggesting better alternatives as per medical practice.
• Encourage use of generics and cost effective quality drugs where indicated as a method of reducing the organizations pharmaceutical expenditure.
• Review documents and pertinent requirements regarding claims from providers and clients.
• Ensure that the claim made by the claimant is complete in form and complies with the documentary requirements of an insurance claim.
• Management of relationships with clients, intermediaries and service providers.
• Verification and audit of outpatient and inpatient claims to ensure compliance and mitigate risk.
• Advice claimants regarding basic matters about their insurance coverage in relation to the insurance claim.
• Respond to both internal and external claims inquiries concerning claims process, service providers, and the filing/completion of proper forms.
• Record all claims transactions.
• Prepare claims registers for claims meetings and update the various claims reports.
• Track and follow up on receipt of necessary documents.
• Delegated Authority: As per the approved Delegated Authority Matrix.

Knowledge, experience and qualifications required

• Degree in Bachelor of Science in Nursing Sciences from a recognized university.
• Professional Nursing qualification KRCHN licensed by Nursing council of Kenya.
• At least two-year experience in case management and claims processing.