MAIN PURPOSE OF JOB:
The Case Manager’s overall purpose is to monitor, evaluate and coordinate medical benefit utilization to ensure quality, appropriate and cost effective care, as well as ensure business relationship with existing, new and potential Medical Service Providers (MSP) is as healthy as possible and that our clients are getting services as promised. The Case Manager will be expected to demonstrate commitment, loyalty and perform all duties in accordance with the CarePay’s office routines and procedures, keeping in mind the overall business objectives. In addition, the Case Manager will assess medical claims (including but not limited to outpatient services) submitted by MSPs and adjudicate such claims including necessary follow up with the MSP. Case Manager will develop and enhance our patient service codes, charges and packages as well as negotiate the best rates.
DUTIES AND RESPONSIBILITIES:
Case Management (In-Patient)
Pre-authorization of scheduled and non-scheduled admissions to ensure validity, legitimacy of admission, and advice on cover scope.
Liaise with physicians to obtain CarePay client medical reports to ensure they are getting optimal, quality care as most appropriate.
Negotiate professional fees for each admission to ensure clients are receiving cost effective care within the scope of their cover.
Support a 24-hour helpline and ensure client enquiries are sorted to satisfaction and assist with medical emergencies logistics.
Visit all admitted clients as part of company PR and to ensure the clients are getting appropriate satisfactory care.
Be responsible for developing and maintaining the CarePay in-patient services coding
Support in training providers, enhancing in-patient platform functionality and platform adoption
Claims Management
Work together with claims manager and assessors within CarePay (“Medical team”) on claim assessment and adjudication of claims backlog for CarePay-managed-schemes (focus on Out-Patient)
Review and assess claims backlog, including necessary follow up with providers to clarify needs (through CarePay’s platform and/or in direct contact)
Support CarePay’s “Medical team” with other relevant tasks, e.g. pricelist and product item code mapping, supporting CarePay platform module development (for claim automation purposes), etc.
Provider Relations (Focus on In-Patient)
For In-Patient services, be the first contact to service providers on disputes from client’s complaints about audit.
Audit existing providers (initially limited to those MSPs which are actively treating cases), to ensure that protocol is adhered to [if not adhered to, make recommendation on next action-suspend/terminate/warning]
Where relevant, support development of CarePay protocols to maintain standards, and support training of MSP on those.
Maintain MSP contacts and un updated contacts.
Maintain report on MSP visits and issues handled.
Develop strong relationships with existing/new/potential MSPs
Renegotiation of terms with existing MSPs within set CarePay guidelines; make recommendations for changing terms outside the job’s guidelines.
Additional roles assigned by the line manager captured above or not.
KEY PERFORMANCE MEASURES:
% of IP cases concluded successfully (i.e. without dispute, within agreed costs, with client satisfaction)
Turn Around Time for pre-authorization requests
Average cost per IP Case treated
Quality of relationships with key service providers (specialists and hospitals) for IP treatments
Customer feedback through various channels e.g. NPS surveys (hospitals, Doctors, patients) Number of (OP) claims assessed
Performance on other medical team tasks as they come (code mapping)
Report on Average IP cost per provider and service type
Savings on negotiated IP costs
Reduction in average length of admission
% of Patients visited within first 24 hrs
EDUCATIONAL QUALIFICATIONS, KNOWLEDGE & EXPERIENCE:
Degree/Higher National Diploma in Nursing or Clinical Medicine.
KRCHN Registration
At least 3-5 years relevant working experience.
Good interpersonal, communication and negotiation skills.
Basic knowledge of computers and office operating programmes.
Experience in an insurance company.
A proven experience to build strong client relationships and maintain an excellent customer focus.
Have strong understanding of medical treatments protocols and habits in relations to market segmentation.
An understanding of confidentiality and data protection issues.
KEY SKILLS AND COMPETENCIES:
Communication skills – Communicates clearly and professionally in written and oral forms to both internal and external clients.
Initiative and Confidence – Generates and acts on new ideas that add value to the business. Looks at different ways to solve problems and address difficulties.
Achievement Drive – Sets goals and strives to achieve them with enthusiasm and determination.
Business Acumen – Has a good understanding of the business environment and the impact their behaviour has on the reputation of the company.
Strong interpersonal skills with ability to work with cross cultural and diverse people and teams
Respect – Treats colleagues and customers in a manner which demonstrates integrity, honesty, and fairness.
Eye for details
Flexible and ability to adapt or change to new situations and handle levels of uncertainty
Discretion in handling confidential information
Personal qualities of integrity, credibility, professionalism, and a commitment to CarePay’s mission and values.
DECISION MAKING AUTHORITY
Undertaking for acute cold cases, emergency situations,
Decisions in emergency situations
Diverting clients to more cost-effective service providers to enable them stay within scope of cover.
Decision to advocate for homecare and rehabilitation where deemed necessary
Renegotiating charges with MSPs
Handling MSP disputes as per the company’s policies
Apply via :
recruitment.carepay.co.ke
