Key responsibilities
Audit and Verify outpatient, inpatient and reimbursement claims as per clinical guidelines and within the recommended guided tariffs.
Ensure regulatory control and drug management on all prescriptions ensuring advice on adverse drug reactions are suspected, or where potential on drug interactions existing and ensuring dosage and medicines are accurately prescribed.
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.
Price guided tariffs- building of provider pricelists especially for bigger providers on average pharmaceutical expenditure.
Trend Analytics – Analysis of prescription patterns for providers and prescription drug use by members based on system-generated reports.
Involvement and participation in formulation of the CPT codes for medicines to track expenditure and provide trend analysis.
Training of medical claims team on current treatment protocols on need basis and best practise.
Audit independent pharmacies and pharmacies within the various hospitals.
Providing of novel strategies on reduction of the company’s pharmaceutical expenditure.
Develops and maintains networks within pharmaceutical sector, keeps updates on current practices, participates in professional societies
Outsourcing of non-pharmaceutical equipment with an aim to reduce costs on hospital mark ups.
Good clinical acumen and keeps up to date with latest trends as provided by ministry of health and any other global bodies
Provide technical support to the claims team on queries revolving around prescription of drugs.
Promptly and efficiently attend to customer queries, and complaints perform any other duties as may be assigned from time to time.
Key Performance Measures
Saving the Company money from wastage and exorbitant fees by providers.
Medical fraud mitigation
System support and integration on CPT coding
Knowledge, experience and qualifications required
Diploma in Pharmacy
At least two years of practise in a busy hospital set up or
At least two years’ experience in medical claims processing in insurance set up
Registered with the Pharmacy and Poison board.
Basic knowledge of insurance concepts
Knowledge of claims processes and procedures
Proficient in use of Microsoft office suites and packages
Core competencies
Good Communication skills
Building Relationships
Focuses on the Customers
Develops Self
Closing Date: Friday, December 9, 2016
Key Skills/Specialization:
Diploma in Pharmacy
At least two years of practise in a busy hospital set up or At least two years’ experience in medical claims processing in insurance set up
Registered with the Pharmacy and Poison board.
