The Case Management Officer is responsible for controlling and managing policies through case management to ensure quality and cost-effective care, client service, and the efficient processing and payment of EMC claims.
Key Responsibilities
Admission Management: Set appropriate parameters for each admission including claim reserves, initial authorized cost, and duration.
Interact with clients and service providers to ensure care is given within policy guidelines.
Service Coordination:
Medical Review: Review medical reports and claims for compliance with set guidelines.
Underwriting Collaboration: Liaise with underwriters on the scope of cover for various schemes.
Member Support: Ensure medical scheme members are attended to round the clock with support from the 24-hour call center.
Pharmaceutical Oversight: Discourage poly-pharmacy by diligent challenging of prescriptions and suggesting better alternatives; encourage generic substitution to reduce expenditure.
Claims Management: Review documents and pertinent requirements regarding claims from providers and clients; ensure claims are complete and comply with documentary requirements.
Relationship Management: Manage relationships with clients, intermediaries, and service providers.
Audit & Risk: Verify and audit outpatient and inpatient claims to ensure compliance and mitigate risk.
Claimant Advisory: Advise claimants regarding basic matters about their insurance coverage in relation to the insurance claim.
Inquiry Handling: Respond to both internal and external claims inquiries concerning processes, service providers, and form completion.
Documentation: Record all claims transactions and prepare/update claims registers for meetings.
Other Duties: Perform any other duties as may be assigned from time to time.
Requirements
Professional Qualification: Professional Nursing qualification (KRCHN) and licensed by the Nursing Council of Kenya.
Experience: At least 2-4 years of experience in case management and claims processing.
Regulatory Knowledge: Knowledge of insurance regulatory requirements.
Product Knowledge: Knowledge of insurance products.
Interested and qualified candidates should apply online through the Britam career portal (hosted on Taleo) via this application link: https://www.myjobmag.co.ke/apply-now/1215291.
