Reporting to the Manager Clinicals, the Case Management Officer will be responsible for controlling and managing the policy cycle through pre-authorization and case management to ensure quality and cost-effective care.
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 care is given within policy guidelines.
Review medical reports and claims for compliance with set guidelines.
Liaise with underwriters on the scope of cover for various schemes.
Ensure medical scheme members are attended to round-the-clock with support from a 24-hour call centre.
Poly-Pharmacy: Discourage poly-pharmacy by diligent challenging of prescriptions and suggesting better alternatives.
Generic substitution: Encourage use of generics where indicated as a method of reducing the organization's pharmaceutical expenditure.
Delegated Authority: Exercise authority as per the approved Delegated Authority Matrix.
Prepare periodic reports for management on medical claims.
Ensure claims are processed within the stipulated time.
Perform any other duties as may be assigned from time to time.
Knowledge, Experience and Qualifications Required
Diploma/Degree in Nursing or Diploma in Clinical Medicine or Diploma in Pharmacy.
Understanding of insurance concepts.
Professional qualification in FLMI, ACII, and IIK would be an added advantage.
3-4 years' experience in case management.
How to Apply
Interested and qualified candidates can apply online through Britam Taleo Portal.
