Job Summary
Case management, handling all outpatient, inpatient, specialized services preauthorization, and communicating with providers, clients, and brokers on a timely basis as per agreed TATs.
Job Description
To perform all the case management roles at the contact centre which includes but not limited to:
Immediate response to calls in relation to call centre guidelines and provide solutions to customers in a professional way.
Respond to all emails and give feedback within the stipulated Procedures TATs. Critically analyse and give accurate response to pre-authorization within 10 minutes of receiving in line with member policy benefits.
Negotiate with providers on All surgical cases for cost containment. The Optometrist to handle all the optical case in addition to the assigned roles.
The clinical officer or pharmacist to vet all prescriptions and other bills to identify any overpriced items.
Mitigate fraud cases through visitation of admitted patients in various hospitals, and vet all inpatient bills.
Discharge patients within 30 minutes, outpatients email response within 10 minutes.
Daily sending of admissions reports of clients: Brokers/Agents/Company Human Resources Managers.
Efficient & accurate submission of approvals in line with the medical policy .
Obtaining medical information from providers with written correspondence if necessary.
Capacity to continually apply negotiation skills with the service providers.
Interacting with clients, Intermediaries and services providers as required to resolve problems in a manner that is legal, ethical, and consistent with the principles of the policy.
Accurate checking and confirming membership validity, benefits and sending member statement upon enquiry.
Accurate guidance on provider network enquiries from brokers, providers, members etc.
Vetting and confirming validity of the service given by the service provider in relation to the member benefit covered, treatment given, adherence to provider panel rules and cost of treatment.
Obtaining additional required information on invoice/claims from providers or clients.
Apply via :
absa.wd3.myworkdayjobs.com
