About the Role

Reporting to the Assistant Manager – Call Centre and Outpatient Services, the role holder will be responsible for timely adjudication of optical claims, in accordance with CIC medical policy provisions, monitoring claim trends, optical cost management, and maintaining expected service level agreements already in place with our clients and stake holders. The role will ensure best clinical practices are adhered to in relation to prescription and dispensation of spectacles, while providing timely and valuable insights for value-based care.

Key Responsibilities

• Accurate adjudication of all Optical claims in accordance to Scheme’s policy provisions.
• Maintenance of high servicing levels by issuing approvals within 15minutes and sharing daily optical TAT report
• In-depth analysis of claim trends and maintenance of accurate revisit registers
• Respond to Optical related calls and email complaints within 24hours of notification and timely escalation as per escalation matrix
• Facilitate issuance of letters of undertaking for scheduled ophthalmological procedures and cases requiring day case and inpatient ophthalmology care
• Institutionalize robust optical and ophthalmological cost management initiatives through discount negotiation, fraud detection and investigation, costing, and optimization of SHA ophthalmological packages.
• Conduct cost versus clinical validation of optical prescriptions, lens and frames choices, diagnoses requirements to prevent inappropriate costing, or incongruent prescriptions.
• Conduct regular Optical provider forensic mystery shopping and physical audits of at least 5 providers quarterly and share audit report with management.
• Negotiate at least 5 preferred Opticians per quarter and help drive traffic to the preferred panel
• Any other duty as may be assigned by the supervisor.

Who We’re Looking For

Essential Knowledge/Skills and Experience Required:

• Diploma in Optometry and Vision Sciences
• Licensed by KHPOAP
• Minimum of 3 (three) years relevant experience in a busy medical environment
• Experience in an insurance firm is an added advantage
• Customer experience training will be an added advantage

Key Competencies:

• High attention to detail and accuracy
• Analytical & problem – solving
• Good communication and stakeholder management skills

• Accurate adjudication of all Optical claims in accordance to Scheme’s policy provisions.
• Maintenance of high servicing levels by issuing approvals within 15minutes and sharing daily optical TAT report
• In-depth analysis of claim trends and maintenance of accurate revisit registers
• Respond to Optical related calls and email complaints within 24hours of notification and timely escalation as per escalation matrix
• Facilitate issuance of letters of undertaking for scheduled ophthalmological procedures and cases requiring day case and inpatient ophthalmology care
• Institutionalize robust optical and ophthalmological cost management initiatives through discount negotiation, fraud detection and investigation, costing, and optimization of SHA ophthalmological packages.
• Conduct cost versus clinical validation of optical prescriptions, lens and frames choices, diagnoses requirements to prevent inappropriate costing, or incongruent prescriptions.
• Conduct regular Optical provider forensic mystery shopping and physical audits of at least 5 providers quarterly and share audit report with management.
• Negotiate at least 5 preferred Opticians per quarter and help drive traffic to the preferred panel
• Any other duty as may be assigned by the supervisor.

• High attention to detail and accuracy
• Analytical & problem – solving
• Good communication and stakeholder management skills

• Diploma in Optometry and Vision Sciences
• Licensed by KHPOAP
• Minimum of 3 (three) years relevant experience in a busy medical environment
• Experience in an insurance firm is an added advantage
• Customer experience training will be an added advantage