Maintain constant contact with hospitals to ensure continuous well-being of all the stakeholders and handling of medical claims with efficiency and accuracy.
Pre-authorise scheduled and non-scheduled admissions within the set guidelines.
Liaise with the hospitals and doctors for prompt discharge plan of the admitted members.
Assess and authenticate inpatient and outpatient medical claim documents.
Ensure smooth discharge process and co-ordinate any necessary post-hospitalisation care.
Prescreening and vetting of inpatient, outpatient and reimbursements claims to ensure adherence to agreed tariffs and clinical protocols, with clearly documented notes in case of decline and any discount offered by the providers.
Conduct hospital visits and monitoring of inpatient bills.
Daily monitoring of interim bills and appropriate interventions for high quality of care.
Daily status reporting of the clinical status of the admitted members.
Contact centre management, pre-authorization approvals on payments and responding to member and provider enquiries.
Ensure timely notification to the stakeholder team of all the declined cases as per the policy guidelines.
Timely resolution of all the complaints raised by clients.
Responding to all clients and providers requests within 24 hours
Ensure all counter guaranteed and roaming cases have official letters before approvals are done.
Authorization of maternity bookings and wellness letters are issued within 24hrs.
Monitoring client with chronic diseases by ensuring managed health care forms are completed by the doctors for proper follow up and management.
Health talks, wellness and check-ups management with providers and all stake holders
Ensure inculcation of the TCF (Treating Customers Fairly) culture
Minimum Qualifications:
Degree or Diploma in Medicine, Nursing, Clinical Officer, or Pharmacy
2 years’ clinical experience
Core Competencies
Understanding of health insurance operations and concepts
Knowledge of medical claims processes and procedures
