Job Purpose:
To effectively process medical claims by verifying and
updating information about submitted claims and reviewing the work processes
required to determine reimbursement. This includes verifying submitted claims,
assessing reimbursement policies, performing reconciliation with claims
estimates, and conducting payment negotiations and providing support on the
process of medical claims.
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.
Poly-Pharmacy – discourage polypharmacy 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.
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.
2-4 years’ experience in claims
management position in a busy insurance environment or an insurance company.
Technical/
Functional competencies
Knowledge of insurance regulatory
requirements.
Knowledge of insurance products.
Sales and marketing management skills.
How To Apply
