Senior Case Management Officer– Wellness & Provider Relations

Job Purpose:

• Supervising Health Care processes and procedures through the use of effective techniques to achieve the objectives of cost, Quality control and operational efficiency.

Key responsibilities:

• Ensure quality & affordable care to all admitted patients.
• Analysis and interpretation of admission, savings and average cost reports for effective cost control.
• Enrolment of members to CDM program and follow up.
• Work with the wellness team to ensure compliance.
• Verification and audit of outpatient and inpatient approval requests as per the claims manual and customer service charter manual to ensure compliance and mitigate risk
• Supervise; train and mentor case management officers to achieve a high level of motivation and productivity by the team.
• Negotiate professional fees and hospital charges including discounts to control expenditure.
• Hold regular business meetings with service providers to ensure compliance on contract terms, use of agreed systems and agreed tariffs.
• Monitor, prevent and control medical claims fraud by carrying out regular audits on the internal and external systems/ processes as well as providers.
• Prepare regular care reports to clients, management and advice medical underwriting section on relevant care findings for medical risk review.
• 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:

• Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
• Professional qualification in Insurance (ACII, FLMI or IIK) – added advantage.
• 6-8 years’ experience in medical claims handling two of which should be in a supervisory position in a busy insurance office.
• Knowledge of insurance concepts.
• Technical/ Functional competencies.
• Knowledge of insurance regulatory requirements.
• Knowledge of insurance products.
• Sales and marketing management skills.