Job Purpose
The role holder will be responsible for controls and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care within Mombasa region.
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.
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 positio
Emerging Leaders Competency Descriptions
Presenting and Communicating Information – Speaks fluently; expresses opinions, information and key points of an argument clearly; presents effectively; responds quickly to others ‘reactions and feedback during conversations; projects credibility.
Working with People – Shows respect for the views and contributions of team members; shows empathy; listens, supports and cares for others; consults others and pro-actively shares information and expertise with them; builds team spirit and reconciles conflict; adapts to the team and fits in well.
Adhering to Principles and Values – Upholds and encourages ethical behavior and departmental values; demonstrates integrity; encourages individual responsibility towards the community and the environment; models the organizational values during every day interactions.
Analyzing – Analyses numerical data and all other sources of information, breaking them into component parts, patterns and relationships; probes for further information or greater understanding of a problem; makes rational judgments from the available information and analysis; demonstrates an understanding of how one issue may be part of a much larger system / process / problem.
Planning and Organizing – Adheres to and monitors clearly defined objectives; plans activities and projects well in advance and takes account of possible changing circumstances; identifies and organizes resources needed to
accomplish tasks; manages time effectively; monitors performance against deadlines and milestones.
Delivering Results and Meeting Customer Expectations – Focuses on customer needs and satisfaction; sets and models high standards for quality and quantity; monitors and maintains quality and productivity; works in a systematic methodical and orderly way; consistently achieves projects goals.
Deciding and Initiating Action – Takes responsibility for own, as well as subordinates’ actions and projects; takes initiative and works under own direction; initiates and generates activity; introduces improvements into work
processes; handles problems with minimal guidance.
Leading and Supervising – Provides subordinates with a clear direction; motivates and empowers others; provides subordinates with the relevant coaching; creates a positive climate that fosters learning and development; identifies high potential talent; sets and articulates the departmental vision and values through own personal behavior; sets appropriate standards of behavior.
Formulating Strategies and Concepts – Works strategically to realize personal goals; understands and effectively communicates the departmental strategy; translates the departmental strategy and vision into operational responsibilities; takes into consideration departmental strategy during all tasks; takes account of a wide range of issues across, and related to current role.
Applying Expertise and Technology – Applies specialist and detailed technical expertise; uses technology to achieve work objectives; develops job knowledge and expertise (theoretical and practical) through continual professional development; demonstrates an understanding of different organizational departments and functions.
Following Instructions and Procedures – Challenges authority only when appropriate; follows procedures and policies; keeps to schedules; arrives punctually for work and meetings; demonstrates a commitment to the organization; complies with legal obligations and safety requirements of the role.
Adapting and Responding to change – Adapts to changing circumstances; tolerates ambiguity; accepts new ideas and change initiatives; adapts interpersonal style to suit different people or situations; shows an interest in new experiences.
Apply via :
britam.taleo.net
