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.
For more information and job application details, see; https://britam.taleo.net/careersection/external+-+britam/jobdetail.ftl?job=2200003Y&tz=GMT%2B03%3A00&tzname=Africa%2FNairobi