Control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.
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
- 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.
- Delegated Authority: As per the approved Delegated Authority Matrix
- Prepare periodic reports for management on medical claims
- Ensure claims are processed within the stipulated time.
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
Emerging Leaders Competency Descriptions.
Presenting and Communicating Information – Speaks fluently; expresses opinions,
information and key points of an argument clearly; presents effectively;
responds quickly to others ‘reactions and feedback during conversations;
projects credibility.
Working with People – Shows respect for the views and contributions
of team members; shows empathy; listens, supports and cares for others;
consults others and pro-actively shares information and expertise with them;
builds team spirit and reconciles conflict; adapts to the team and fits in
well.
Adhering to Principles and Values – Upholds and encourages ethical behavior and
departmental values; demonstrates integrity; encourages individual
responsibility towards the community and the environment; models the
organizational values during every day interactions.
Analyzing – Analyses numerical data and all other sources of information, breaking
them into component parts, patterns and relationships; probes for further
information or greater understanding of a problem; makes rational judgments
from the available information and analysis; demonstrates an understanding of
how one issue may be part of a much larger system / process / problem.
Planning and Organizing – Adheres to and monitors clearly defined
objectives; plans activities and projects well in advance and takes account of
possible changing circumstances; identifies and organizes resources needed to
accomplish tasks; manages time effectively; monitors performance against
deadlines and milestones.
Delivering Results and Meeting Customer
Expectations – Focuses on customer
needs and satisfaction; sets and models high standards for quality and
quantity; monitors and maintains quality and productivity; works in a
systematic methodical and orderly way; consistently achieves projects goals.
Deciding and Initiating Action – Takes responsibility for own, as well as
subordinates’ actions and projects; takes initiative and works under own
direction; initiates and generates activity; introduces improvements into work
processes; handles problems with minimal guidance.
Leading and Supervising – Provides subordinates with a clear
direction; motivates and empowers others; provides subordinates with the
relevant coaching; creates a positive climate that fosters learning and
development; identifies high potential talent; sets and articulates the
departmental vision and values through own personal behavior; sets appropriate
standards of behavior.
Formulating Strategies and Concepts – Works strategically to realize personal
goals; understands and effectively communicates the departmental strategy;
translates the departmental strategy and vision into operational
responsibilities; takes into consideration departmental strategy during all
tasks; takes account of a wide range of issues across, and related to current
role.
Applying Expertise and Technology – Applies specialist and detailed technical
expertise; uses technology to achieve work objectives; develops job knowledge
and expertise (theoretical and practical) through continual professional
development; demonstrates an understanding of different organizational
departments and functions.
Following Instructions and Procedures – Challenges authority only when appropriate;
follows procedures and policies; keeps to schedules; arrives punctually for
work and meetings; demonstrates a commitment to the organization; complies with
legal obligations and safety requirements of the role.
Adapting and Responding to change – Adapts to changing circumstances; tolerates
ambiguity; accepts new ideas and change initiatives; adapts interpersonal style
to suit different people or situations; shows an interest in new experiences.
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