Care Management, handling all inpatient and specialized test preauthorization, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns.
Undertaking of admissions (including declines).
Data collection for Pre-authorizations and high claimant bills.
Ensure appropriate Turnaround Time is adhered to in issuing inpatient and outpatient approvals.
Seeking medical clarifications including medical reports, copies of investigation reports, etc.
Broker/customer relations by communicating all necessary admission claim decisions on a timely basis.
Care Management – Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise for declines, ensuring that the decisions are accurate and a correct interpretation of the policy.
Work with the inpatient claims assessor(s) for inpatient claims and coordinating on any information noted in the inpatient claim submitted especially in cases where further information provided changes the position undertaken previously on the claim.
Reviewing medical pre-authorizations for compliance with applicable policy guidelines.
Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is legal, ethical, and consistent with the principles of the policy.
Checking and confirming membership validity and benefits (from the scheme benefits file).
Handling of coverage enquiries with brokers, providers, members etc.
Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.
Obtaining additional required information on claims from providers, brokers, or clients.
Liaising with our underwriting section on scope of cover for various schemes.
Assisting in conducting provider audits wherever necessary.
Client presentations and member education on wise utilization & risk management.
Managing the 24-hour emergency helpline.
Performance reporting and management
Health Benefits Plan Management
Intelligence and Business Development skills
A Bachelor’s degree in Nursing or Clinical Medicine and Surgery
Insurance Professional qualification
Proficient in the use of Microsoft Office Suite and packages
Minimum of 5 years’ experience in a similar role in the insurance industry
Method of Application
If you are qualified and seeking an exciting new challenge, please apply via Recruitment@jubileekenya.com quoting the Job Reference Number and Position by 21st April 2023