Overall Job purpose
Reporting to the Assistant Manager, Medical the role holder shall process medical claims with a focus of providing clinical guidance in pharmacy, ensuring management of member benefits and cost control through designing strategies to ensure proper and cost effective care to members.
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.
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
Good clinical acumen and keeps up to date with latest trends as provided by ministry of health and any other global bodies
Promptly and efficiently attend to customer queries and complaints perform any other duties as may be assigned from time to time.
Handle the 24 hr Helplines
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 an insurance set up
Technical Competencies
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
Essential Competencies
Learning & Researching
Working with people
Applying Expertise and Technology
Delivering Results and Meeting customer expectations
Following instructions & Procedures
Adhering to principles and values
Desirable Competencies
Achieving personal work goals and objectives
Writing and Reporting
Analysing
Planning & Organizing
Adapting and responding to change
Coping with pressures and setbacks
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