Job Purpose: 

• Reporting to the Manager Clinicals, the role holder will be responsible for control and managing of 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 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.
• Ensure that medical scheme members are attended to round the clock with support from 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 organizations pharmaceutical expenditure.
• Delegated 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.