Job Purpose:

To effectively process medical claims by verifying and updating information about submitted claims and reviewing the work processes required to determine reimbursement. This includes verifying submitted claims, assessing reimbursement policies, performing reconciliation with claims estimates, and conducting payment negotiations and providing support on the process of medical claims.

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.
• Poly-Pharmacy – discourage polypharmacy 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.
• Perform any other duties as may be assigned from time to time.

Knowledge, experience and qualifications required

• Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
• Moderate understanding of insurance concepts
• 2-4 years’ experience in claims management position in a busy insurance environment or an insurance company.

• 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.
• Poly-Pharmacy – discourage polypharmacy 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.
• Perform any other duties as may be assigned from time to time.

• Claims management
• Medical report review
• Policy guideline adherence
• Underwriting liaison
• Pharmaceutical expenditure reduction
• Report preparation

• Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
• Moderate understanding of insurance concepts.