Job Detail

• Responsible for the development and implementation of clinical practice management aimed at providing leadership in the provision of healthcare to our members, as well as managing costs and Healthcare outcomes.
• Develop and implement a Managed Care strategy aimed at coordinating medical care to achieve good patient experience, better treatment outcomes, and reduced healthcare costs.
• Manage contracts with service providers, including developing innovative reimbursement options and positioning Britam as a partner to the providers.
• Overseeing case management practices to ensure quality and sustainability. 
• Provide leadership in developing metrics for measuring quality outcomes and obtain collaboration with service providers in meeting the set standards.
• Provide leadership in the utilization of clinical and claims data to develop innovative products and processes that provide a competitive advantage to Britam in health insurance services.
• Overall responsibility for managing chronic conditions and inpatient services cost outcomes through the wellness program.
• Guiding the business in compliance with health regulations relating to health insurance.
• Monitor, prevent, and control medical claims fraud by carrying out regular audits on the internal and external systems/ processes, as well as providers.
• Supervise, train, and mentor medical case management, Wellness Call Centre staff to achieve a high level of motivation and productivity by the team.
• Prepare regular reports to clients, management, and advise the medical underwriting section on relevant claims findings for medical risk review.
• Delegated Authority: As per the approved Delegated Authority Matrix.

Knowledge, experience, and qualifications required

• Bachelor’s degree in a medical-related field
• Professional qualification in Insurance (ACII or IIK)
• 2 - 6 years’ experience in medical, with at least 2 years in a supervisory position.
• Experience in managing complex medical insurance operations (Claims, case management, and provider network)