Controlling and Managing policies through case management to ensure quality and cost effective care, client service, provider management, processing and payment of EMC 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.
Ensure that medical scheme members are attended to round the clock with support from 24 hour call centre.
Discourage poly-pharmacy by diligently challenging of prescriptions and suggesting better alternatives as per
medical practice.
Encourage use of generics and cost effective quality drugs where indicated as a method of reducing the
organizations pharmaceutical expenditure.
Review documents and pertinent requirements regarding claims from providers and clients.
Ensure that the claim made by the claimant is complete in form and complies with the documentary requirements
of an insurance claim.
Management of relationships with clients, intermediaries and service providers
Verification and audit of outpatient and inpatient claims to ensure compliance and mitigate risk.
Advice claimants regarding basic matters about their insurance coverage in relation to the insurance claim.
Respond to both internal and external claims inquiries concerning claims process, service providers, and the
filing/completion of proper forms.
Record all claims transactions.
Prepare claims registers for claims meetings and update the various claims reports.
Track and follow up on receipt of necessary documents.
Delegated Authority: As per the approved Delegated Authority Matrix.
Knowledge, experience and qualifications required
Degree in Bachelor of Science in Nursing Sciences from a recognized university.
Professional Nursing qualification KRCHN licensed by Nursing council of Kenya.
At least two-year experience in case management and claims processing.
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.
