Job Description

• Through due diligence, issue undertakings in line with the policy provisions. Likewise, for declines or part approvals, ensuring that the decisions are accurate and a correct interpretation of the policy.
  
• Review patient’s history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.
  
• Pre-authorize admission, discharges, scheduled and emergency medical cases, issue timely responses as per policy benefits and company guidelines.
  
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.
  
• Conduct admitted patients visits and daily follow-ups, ensuring they receive quality and cost-effective care
  
• Ensure appropriate Turnaround Time is adhered to in issuing approvals, letters of undertaking and correspondence.
  
• Collaborate with Brokers/ Agents/ Corporates/Customer relations by communicating and updating them with necessary admission claim decisions on a timely basis.
  
• Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is timely, ethical and consistent with the First Assurance policy, applicable legal and regulatory requirements.
  
• Negotiating with providers, doctors, hospitals on cost, tariffs, discounts, pre-agreed rates, packages, fixed cost model
  
• 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.
  
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
  
• Collaboration with Cross-Functional Teams: Working closely with various departments like provider relations, call center, claims, underwriting, audit to address customer needs and provide comprehensive solutions.
  
• Undertaking presentations and member education on wise utilization & risk management
  
• Daily review of admitted patients’ treatment plans, monitor improvements, bill escalation and provide guidance on coverage, inform intermediaries and ensure care coordination.
  
• Follow through and resolve escalated customers and provider queries and complaints in time and advise them on outcome and the details of the medical product.
  
• Advise members on how best to utilize their benefits by recommending cost effective facilities and cheaper options e.g., maternity packages, chronic management.
  
• Generate, recommend and implement preventive care program through health talks, wellness and the chronic disease management program CDMP.
  
• Process Improvement and Innovation: Identifying areas for process enhancement, suggesting improvements and implementing innovative solutions to streamline operations
  
• Send weekly and monthly report on admissions, exceptional claims, long stay, savings amongst others.
  
• Observe confidentiality of client information and compliance with the Data Protection Act
  
• Performs all other tasks as assigned by line manager.
  

Knowledge Management

• Improve technical knowledge through self-learning or training including mandatory Continuous Professional Education requirements.
  
• Share knowledge with colleagues and peers in the business.
  
• Develop and enhance learning through seeking coaching, training and continual feedback
  

Reporting

• Sending daily admissions reports to clients; Brokers/Agents/ company Human resource managers.
  
• Prepare and compile section reports on daily, weekly and monthly basis and forwards to the management.
  

Relationship management

• Develop and maintain relationships with colleagues and clients; Brokers/Agents/ company Human resource managers.
  

Education, Experience Required and Competencies:

• Technical Skills: Proficiency Microsoft Office Suite
  
• Education: Bachelor’s Degree/Diploma in Nursing (KRCHN)/ Clinical Medicine/ Health Management or in a related field.
  
• Experience Level: Minimum 2 years of clinical experience and 1 year case management experience
  
• Soft Skills: Excellent communication skills, empathy, negotiations, problem-solving abilities, adaptability, excellent communication and a customer-centric approach.
  
• Industry Knowledge: Understanding of insurance policies, regulations, compliance and standards
  
• Licensed by relevant statutory regulator in his/her respective medical field.
  

• Member of relevant professional medical association in good standing.