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 as well as support of all retention strategies.
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.
- Analyze proposed risks and make decisions to accept or reject.
- Determine the rates and terms to charge.
- Ensure risk survey recommendations are communicated in time
and follow up implementation.
- Ensure underwriters comply to the company credit policy.
- Build and manage relationships with brokers, agents, and other
intermediaries.
- Monitor market trends and competitor activities to stay
informed about industry developments and stay updated on changes in laws
and regulations that may affect client retention efforts.
- Work closely with sales, marketing, actuarial, to align
retention strategies with business goals.
- Proactively manage the policy renewal process to ensure timely
renewals and minimize lapses in coverage.
- Review and negotiate renewal terms and conditions with clients
to retain their business.
- Develop and implement strategies to improve client retention
rates.
- 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/ Diploma in clinical medicine/
Diploma in Pharmacy/ Bachelor’s degree (insurance option preferred).
- Progress in Professional qualification in Insurance (ACII,
FLMI or IIK).
- 1-3 years’ experience in Health.
- Proven experience in managing and nurturing client
relationships.
- Track record of achieving client satisfaction and retention
targets.
Technical/
Functional competencies:
- Knowledge of insurance regulatory requirements.
- Knowledge of insurance products.
- Sales and marketing management skills.
How
To Apply
