Controlling and Managing policies through case management to ensure quality and cost effective care., client service, processing and payment of EMC claims.
- 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.
- 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.
- 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:
- Professional Nursing qualification KRCHN licensed by Nursing council of Kenya.
- At least one-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 optimize 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 optimize 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 organizational 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.