Primary Responsibility:

Care Management, handling Outpatient, Optical and Dental preauthorizations, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns and managing the 24-hour emergency line.

Key Responsibilities:

• 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
• Ensure appropriate Turnaround Time is adhered to in issuing approvals.
• Seeking medical clarifications including medical reports, copies of investigation reports from providers as per standard procedure.
• Broker/customer relations by communicating all necessary claim decisions to clients on a timely basis.
• Work with the claims team and providing on any information required in the claims submitted in cases where further information provided changes the position undertaken previously on the claim.
• Interacting with clients, brokers and providers as needed, to resolve problems in a manner that is legal, ethical and consistent with the principles of the policy.
• Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost and average cost agreements.
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
• Liaising with underwriting department on scope of cover for various schemes
• Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc
• Managing the 24-hour emergency helpline
• Implementation of strategic initiatives for the department and recommendations by claims QA committee.
• Achieve an NPS scope on all customer service indicators.
• Compliance to internal business processes, IRA Regulations/guidelines and adherence to work Ethics for the department
• Client presentations and member education on wise utilization & risk management
• Support the care management team to ensure all the deliverables are met within the given turnaround time

Skills and Competencies Required

• Health Benefits Plan Management
• Policy Interpretation
• Customer Service and Focus
• Responsibility & commitment
• Team Spirit
• Excellent communication
• Ability to multi-task
• Strong negotiation and decision-making skills

Knowledge & Work Experience

• At least 2 years’ case management or relevant experience.
• Demonstrated knowledge of managing admissions and discharges

Academic and Professional Qualifications required

Bachelor’s degree in nursing or clinical medicine

• 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
• Ensure appropriate Turnaround Time is adhered to in issuing approvals.
• Seeking medical clarifications including medical reports, copies of investigation reports from providers as per standard procedure.
• Broker/customer relations by communicating all necessary claim decisions to clients on a timely basis.
• Work with the claims team and providing on any information required in the claims submitted in cases where further information provided changes the position undertaken previously on the claim.
• Interacting with clients, brokers and providers as needed, to resolve problems in a manner that is legal, ethical and consistent with the principles of the policy.
• Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost and average cost agreements.
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
• Liaising with underwriting department on scope of cover for various schemes
• Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc
• Managing the 24-hour emergency helpline
• Implementation of strategic initiatives for the department and recommendations by claims QA committee.
• Achieve an NPS scope on all customer service indicators.
• Compliance to internal business processes, IRA Regulations/guidelines and adherence to work Ethics for the department
• Client presentations and member education on wise utilization & risk management
• Support the care management team to ensure all the deliverables are met within the given turnaround time

• Health Benefits Plan Management
• Policy Interpretation
• Customer Service and Focus
• Responsibility & commitment
• Team Spirit
• Excellent communication
• Ability to multi-task
• Strong negotiation and decision-making skills

• Bachelor’s degree in nursing or clinical medicine