This role is responsible for the effective processing of medical claims by verifying and updating information about submitted claims and reviewing the work processes required to determine reimbursement. The officer ensures that medical care is provided within policy guidelines, performs reconciliation with claims estimates, and conducts payment negotiations while providing comprehensive support throughout the medical claims process.
Key Responsibilities
Claim Parameters: Set appropriate parameters for each admission, including claim reserves, initial authorized costs, and durations.
Liaison: Interact with clients and service providers to ensure care is provided within established policy guidelines.
Compliance Review: Review medical reports and claims for strict compliance with set guidelines and liaise with underwriters on the scope of cover for various schemes.
Clinical Management: Discourage polypharmacy by challenging prescriptions and suggesting better alternatives; encourage generic substitution to reduce pharmaceutical expenditure.
Authority & Reporting: Operate within the approved Delegated Authority Matrix and prepare periodic management reports on medical claims.
Efficiency: Ensure all claims are processed within stipulated timelines and perform other duties as assigned.
Requirements and Qualifications
Education: A Diploma or Degree in Nursing, a Diploma in Clinical Medicine, or a Diploma in Pharmacy.
Experience: 2-4 years of experience in a claims management position within a busy insurance environment or insurance company.
Knowledge: A moderate understanding of insurance concepts and medical underwriting principles.
How to Apply
Interested and qualified candidates should apply online through the Britam career portal at https://www.myjobmag.co.ke/apply-now/1172316. Ensure your application is submitted before the position is filled.
