Assistant Claims Officer

Job Purpose:

Control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.

Key responsibilities:

Ensure all received claims are vetted and released to finance on time (Credit and reimbursement claims).

Set the appropriate parameters for each admission and claims for IP and OP (claim reserve, initial authorized cost and duration).

Interact with clients and service providers to ensure that the care is given within policy guidelines.

Review medical reports and claims for compliance with set guidelines.

Liaise with underwriters on scope of cover for the various schemes.

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 organizations pharmaceutical expenditure.

Prepare periodic reports for management on medical claims.

Ensure claims are processed within the stipulated time.

Delegated Authority: As per the approved Delegated Authority Matrix.

Key Performance Measures:

As described in your Personal Score Card.

Knowledge, experience and qualifications required

Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.

Moderate understanding of insurance concepts.

Professional qualification in FLMI, ACII and IIK.

5-8 years’ experience in case management two of which should be in a supervisory position.

Industries:Health, Wellness & Fitness

Function: Others