Job Purpose:
Controlling and Managing policies through case management to ensure quality and cost effective care, client service, provider management, processing and payment of claims.
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.
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.
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