Job Purpose:
To effectively process medical claims by verifying and updating information about submitted claims and reviewing the work processes required to determine reimbursement. This includes verifying submitted claims, assessing reimbursement policies, performing reconciliation with claims estimates, and conducting payment negotiations and providing support on the process of medical 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.
Poly-Pharmacy – discourage polypharmacy 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.
Delegated Authority: As per the approved Delegated Authority Matrix
Prepare periodic reports for management on medical claims.
Ensure claims are processed within the stipulated time.
Knowledge, experience and qualifications required:
Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
Moderate understanding of insurance concepts.
2-4 years’ experience in claims management position in a busy insurance environment or an insurance company.
Technical/ Functional competencies:
Knowledge of insurance regulatory requirements.
Knowledge of insurance products.
Sales and marketing management skills.
Leadership category responsibility framework (Core Competencies)
Emerging Leaders in Britam need to:
Plan, direct and apply efficiencies and resources in order to optimise output and profitability against time, cost and team targets.
Effectively communicate strategic and operational departmental goals and objectives to peers and others in order to ensure proper implementation.
Ensure that department priorities are adhered to and effectively communicated.
Ensure competent and effective people resources through appropriate coaching, development and people supervision as appropriate.
Embody a high performance, proactive culture.
Effectively ensure the adherence to key performance areas, deadlines and goals in order to optimise operational effectiveness.
Effectively communicate resource needs, possible opportunities and achievements to
management in order to aid them in their decision-making.
Effectively set and monitor priorities and objectives for more junior staff.
Understand and communicate objectives in relation to the larger organisational impact.
Effectively disseminate knowledge within the correct context, towards subordinates as well as management.
Appropriately model the company values while setting the pace and energy for delivering.
Effectively manage and communicate change within the department in order to increase staff and process effectiveness.
Provide access to accurate and consistent information and services across all channels.
Ensure a seamless experience for clients.
Improve service delivery for clients.
Engage in continuous brand building to become the trusted partners to clients.
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