Emerging Consumers, Medical Claims Assistant at Britam

March 10, 2023
Application Ends: March 24, 2023
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Job Description

Job Purpose:

Controlling and Managing policies through case management to ensure quality and cost effective care., client service, 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.
  • 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.