Case Management Officer

Job Purpose:  

• Controlling and Managing policies through case management to ensure quality and cost effective care, client service, processing and payment of Britam Microinsurance 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.  
• Ensure that medical scheme members are attended to round the clock with support from 24  hour call centre.  
• 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.  
• Review documents and pertinent requirements regarding claims from providers and clients.  
• Ensure that the claim made by the claimant is complete in form and complies with the  documentary requirements of an insurance claim 
• Management of relationships with clients, intermediaries and service providers.  
• Verification and audit of outpatient and inpatient claims to ensure compliance and mitigate risk.  
• Advice claimants regarding basic matters about their insurance coverage in relation to the insurance claim.  
• Respond to both internal and external claims inquiries concerning claims process, service providers, and the filing/completion of proper forms.  
• Record all claims transactions.   
• Prepare claims registers for claims meetings and update the various claims reports.  Track and follow up on receipt of necessary documents.  
• Delegated Authority:  As per the approved Delegated Authority Matrix.  
• Perform any other duties as may be assigned from time to time. 

Knowledge, experience and qualifications required:  

• Professional Nursing qualification KRCHN licensed by Nursing council of Kenya. 
• At least 2 -4 years experience in case management and claims processing.  
• Knowledge of insurance regulatory requirement  
• Knowledge of insurance products.