Reporting to the Assistant Manager – Call Centre and Outpatient Services, the Optometry Officer will be responsible for the timely adjudication of optical claims in accordance with CIC medical policy provisions. The role involves monitoring claim trends, managing optical costs, and maintaining expected service level agreements with clients and stakeholders. The officer ensures that best clinical practices are adhered to regarding the prescription and dispensation of spectacles, while providing timely and valuable insights for value-based care.
Key Responsibilities
Claims Adjudication: Ensure accurate adjudication of all Optical claims in accordance with the scheme's policy provisions.
Service Level Maintenance: Maintain high service levels by issuing approvals within 15 minutes and sharing daily optical Turnaround Time (TAT) reports.
Trend Analysis: Conduct in-depth analysis of claim trends and maintain accurate revisit registers.
Communication: Respond to optical-related calls and email complaints within 24 hours of notification and ensure timely escalation as per the escalation matrix.
Letters of Undertaking: Facilitate the issuance of letters of undertaking for scheduled ophthalmological procedures and cases requiring day-case and inpatient ophthalmology care.
Cost Management: Institutionalize robust optical and ophthalmological cost management initiatives through discount negotiation, fraud detection and investigation, costing, and optimization of SHA ophthalmological packages.
Clinical Validation: Conduct cost versus clinical validation of optical prescriptions, lens and frame choices, and diagnosis requirements to prevent inappropriate costing or incongruent prescriptions.
Audits: Conduct regular optical provider forensic mystery shopping and physical audits of at least five providers quarterly and share audit reports with management.
Provider Networking: Negotiate with at least five preferred opticians per quarter and help drive traffic to the preferred panel.
Other Duties: Perform any other duties as may be assigned by the supervisor.
Requirements and Qualifications
Education: Diploma in Optometry and Vision Sciences. The candidate should also ideally hold a BA/BSc/HND as per the general qualification standards.
Licensing: Must be licensed by the Kenya Health Professions Oversight and Advisory Board (KHPOAP).
Experience: A minimum of 3 (three) years of relevant experience in a busy medical environment.
Industry Knowledge: Experience in an insurance firm is an added advantage.
Training: Customer experience training will be considered an added advantage.
Key Competencies
High attention to detail and accuracy.
Strong analytical and problem-solving skills.
Good communication and stakeholder management skills.
How to Apply
Interested and qualified candidates should apply online through the CIC Insurance careers portal at https://www.myjobmag.co.ke/apply-now/1198699 which redirects to the official careers site (careers.cicinsurancegroup.com).
How to Apply
Interested and qualified candidates should apply by visiting the CIC Insurance careers page via the following link: https://www.myjobmag.co.ke/apply-now/1198699. Follow the instructions on the portal to submit your application on careers.cicinsurancegroup.com.
