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Case Management Officer (Fixed-Term Contract) – (2500002Q)
Job Purpose and Key responsibilities
Job Purpose:
Controlling and Managing policies through case management to ensure quality and cost effective healthcare, client service, provider management, processing provider claims and clients for payment.
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.
- Process claims and claims vetting.
- 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
