Job Purpose and Key responsibilities
- Control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.
- 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.
- 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
- Perform any other duties as may be assigned from time to time.
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
Leadership category responsibility framework (Core Competencies)
Emerging Leaders in Britam need to:
- Plan, direct and apply efficiencies and resources in order to optimise output and profitability against time, cost and team targets;
- Effectively communicate strategic and operational departmental goals and objectives to peers and others in order to ensure proper implementation;
- Ensure that department priorities are adhered to and effectively communicated;
- Ensure competent and effective people resources through appropriate coaching, development and people supervision as appropriate;
- Embody a high performance, proactive culture;
- Effectively ensure the adherence to key performance areas, deadlines and goals in order to optimise operational effectiveness;
- Effectively communicate resource needs, possible opportunities and achievements to management in order to aid them in their decision-making;
- Effectively set and monitor priorities and objectives for more junior staff;
- Understand and communicate objectives in relation to the larger organisational impact;
- Effectively disseminate knowledge within the correct context, towards subordinates as well as management;
- Appropriately model the company values while setting the pace and energy for delivering;
- Effectively manage and communicate change within the department in order to increase staff and process effectiveness;
- Provide access to accurate and consistent information and services across all channels;
- Ensure a seamless experience for clients;
- Improve service delivery for clients;
- Engage in continuous brand building to become the trusted partners to clients.
Technical/ Functional competencies
- Knowledge of insurance regulatory requirements
- Knowledge of insurance products
- Sales and marketing management skills.
How to Apply
Unposting Date: 20-08-2022