Medical Care Associate – MombasaJob Purpose
The role holder will be responsible for controls and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care within Mombasa region.
- 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.
- 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.
- 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
How to Apply