Job Purpose:
Controlling and Managing policies through case management to ensure quality and
cost effective care, client service, provider management, processing and
payment of 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.
- Nursing Jobs In Nairobi
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.
How To Apply
