Purpose for the Job

To support the clinical functions in the division by reviewing all preauthorization requests with the relevant medical teams, engaging with Medical Officers within medical facilities for any disputed cases, and supervising Quality Assurance of the medical functions (Pre-authorization and Claims) with a view to enhanced Customer Experience.

Duties and Responsibilities

Operational Roles and Responsibilities

• To adhere to the set protocols and matrix of management of preauthorization requests.
• Ensure next level management of disputed medical cases – i.e. communication to the satisfaction of the member.
• Supervise the Quality Assurance team that provides oversight over the Preauthorization and Claims functions.
• Thought Leadership through insightful articles.
• Preparation of adequate packages and price lists for service provider contracts.
• Continuous training and upskilling of the pre-authorization and claims personnel within the division.
• Any other duties as may be assigned by the supervisor.

Key Result Areas

The accountability areas are as follows:

• Positive Customer Experience
• Enhanced Quality of Service
• Policy guidance
• Care options information
• Discount negotiations/Cost Control

Requirements

Key Competencies

• Benefit coordination
• Conflict resolution

Knowledge And Skills Required

• At least 5 years’ experience in relevant field
• Communication skills
• Detail oriented
• Interpersonal skills
• Negotiations skills
• Leadership skills

Professional and Academic Qualifications

• Bachelor of Medicine and Bachelor of Surgery
• A Masters degree in a medical field
• Registration with the KMDPB