Job Description
To control and manage medical benefit utilization through preauthorization and case management activities and ensure quality, appropriate cost effective care and good customer service
Key Tasks And Responsibilities
- Pre-authorize scheduled and nonscheduled admissions within the set guidelines.
- Negotiate/discuss professional fees as appropriate for each admission.
- Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
- Visit all admitted clients within Nairobi region and its environs
- Liaise with Doctors on the day to day management of patients and obtain medical reports/ expected length of stay where indicated.
- Ensure smooth discharge process and co-ordinate any necessary post-hospitalization/ step down facility care.
- Revise reserves after discharge of member.
- Collect feedback from admitted clients on quality and scope of service by the service provider.
- Assist in carrying out verification and medical audit of claims/invoices before settlement.
- Develop and maintain monthly database on admissions, large claims and extended length of stay.
- Respond to queries from clients, intermediaries and service providers.
- Liaise with other medical underwriter for purposes of market surveys and development of new controls, standards and products.
- Any other duty assigned by management.
Skills And Competencies
- Excellent communication and negotiation skills.
- Excellent public relations and interpersonal relationship skills.
- Extensive networking with SP and other medical insurers.
- Excellent analytical and monitoring skills
- Good IT skills in database management and office systems.
- Good decision making in benefit utilization management.
- High levels of integrity and honesty
Qualifications, Knowledge & Experience
- Diploma or Degree in Nursing
- Diploma in Insurance/ COP
- Degree in Health systems Management/ Business management
- 3 years’ experience in clinical setting +2 years in insurance set up
SkillsEducationClosing Date
08 September 2023
