Britam is a leading diversified financial services group, listed on the Nairobi Securities Exchange. The group has interests across the Eastern and Southern Africa region, with operations in Kenya, Uganda, Tanzania, Rwanda, South Sudan, Mozambique and Malawi. The group offers a wide range of financial products and services in Insurance, Asset management, Ban...

Job Purpose:

Control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.

Key responsibilities:

• Ensure all received claims are vetted and released to finance on time (Credit and reimbursement claims).
• Set the appropriate parameters for each admission and claims for IP and OP (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 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.
• Prepare periodic reports for management on medical claims.
• Ensure claims are processed within the stipulated time.
• Delegated Authority: As per the approved Delegated Authority Matrix.

Key Performance Measures:

As described in your Personal Score Card.

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.

• Ensure all received claims are vetted and released to finance on time (Credit and reimbursement claims).
• Set the appropriate parameters for each admission and claims for IP and OP (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 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.
• Prepare periodic reports for management on medical claims.
• Ensure claims are processed within the stipulated time.
• Delegated Authority: As per the approved Delegated Authority Matrix.

• Moderate understanding of insurance concepts.
• Case management
• Supervisory skills
• Medical report review
• Liaising with underwriters
• Challenging prescriptions
• Reporting

• Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
• Professional qualification in FLMI, ACII and IIK.