Job Detail

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

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 optimise 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 optimise 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 organisational 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.