Job Description
To control and manage medical benefit utilization
through preauthorization and case management activities and ensure quality,
appropriate cost-effective care and good customer service
Key Responsibilities
Pre-authorize scheduled and non-scheduled admissions
within the set guidelines.
Negotiate/discuss professional fees as appropriate
for each admission.
Set the appropriate parameters for each admission
(claim reserve, initial authorized cost and duration).
Visit all admitted clients within Nairobi region and
its environs
Liaise with Doctors on the day-to-day management of
patients and obtain medical reports/ expected length of stay where indicated.
Ensure smooth discharge process and co-ordinate any
necessary post-hospitalization/ step down facility care.
Revise reserves after discharge of member.
Collect feedback from admitted clients on quality and
scope of service by the service provider.
Assist in carrying out verification and medical audit
of claims/invoices before settlement.
Develop and maintain monthly database on admissions,
large claims and extended length of stay.
Respond to queries from clients, intermediaries and
service providers.
Liaise with other medical underwriter for purposes of
market surveys and development of new controls, standards and products.
Any other duty assigned by management.
Skills And Competencies
Excellent communication and negotiation skills.
Excellent public relations and interpersonal
relationship skills.
Extensive networking with SP and other medical
insurers.
Excellent analytical and monitoring skills
Good IT skills in database management and office
systems.
Good decision making in benefit utilization
management.
High levels of integrity and honesty
Qualifications
Diploma or Degree in Nursing
Diploma in Insurance/ COP
Degree in Health systems Management/ Business
management
3 years’ experience in clinical setting +2 years in
insurance set up
How To Apply
