The jobholder will oversee effective deployment of the cost management and profitability strategies for the healthcare business to achieve the budgeted claims ratio, optimize operational efficiencies in business processes in Medical Services Department which includes Care Management, Call Centre and Provider and Wellness Management and deliver exceptional customer experience.

Key Responsibilities

• Develop and implement the strategy for Medical Services Department in liaison with relevant stakeholders to achieve the desired profitability outcomes for the healthcare business
• To ensure achievement of the targeted claims ratio in line with the business strategy and set budgets as it may be stated from time to time
• Oversee the Care Management, Provider Management and Wellness functions in the healthcare business to ensure they achieve the desired performance outcomes for the business
• Engage and establish relationships with our wide panel of hospitals, pharmaceutical companies and doctors/specialists, negotiate for partnerships, packages and discounts and periodically review the panel to ensure alignment and adherence with cost management strategies for the healthcare business
• Oversee Emergency Call Centre Operations and ensure compliance with the customer service benchmarks and charter
• Supervise, train and mentor medical services staff to achieve a high level of motivation and productivity and ensure all staff meet their set KPI’s and departmental targets
• Comply with statutory, regulatory and internal control processes at the departmental level including internal & external audits recommendations.
• Monitor, prevent and control healthcare claims fraud by carrying out regular audits on the internal and external systems and processes, as well as service providers.
• Regular reporting of operational statistics in care management, provider and wellness management e.g. morbidity rates, length of stay, average costs, frequency of claims, savings through packages and partnerships, discounts earned, ailments reports, costs per service providers, etc.
• Continuous review of the chronic disease management strategy and enhancement of the CDM wellness program to improve health outcomes for our clients
• Provide input to the underwriting, claims, business development teams and other stakeholders in setting cover terms, pricing, clinical reviews and medical peculiarities, etc. to improve overall business outcomes
• Monitor developments in the healthcare industry and recommend appropriate strategies to address such developments

Skills and Competencies Required

• Strong leadership and management skills
• Ability to work independently and build effective interpersonal relations
• Bias towards innovation and development of new ideas in problem solving
• Professionalism in dealing with both internal and external stakeholders
• Excellent communication and negotiation skills.
• Extensive networking with service providers and other medical insurers
• Excellent analytical and monitoring skills
• Ability to evaluate decisions made in benefit utilization management
• Integrity and honesty

Knowledge & Experience

• Demonstrated knowledge of managed care practices, medical claims management and business operations.
• At least 5 years’ managerial experience in busy medical insurance environment.
• Addressing operational concerns and issues, monitoring overall customer satisfaction.
• Demonstrated experience engaging service providers at high level, and experience negotiating claims handling terms with providers
• Developing and implementing operational procedures and policies.

Academic and Professional Qualifications required

• Bachelor of Medicine and Bachelor of Surgery (MBChB)
• ACII or AIIK qualifications
• Master’s Degree is an added advantage