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
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.
