Your time is now to be your exceptional best at Old Mutual!
Job Description
To control and manage medical benefit utilization through supervision of pre-authorization and case management and thereby ensure quality, appropriate and cost effective care.
• Pre-Authorization of all admissions within 6 hours and technical guidelines.
Case Management of all admissions as per the set technical guidelines within 12 hours.
• Ensure that all professional fee charges should be within pre-negotiated or set fees guidelines (KMPDB Rates)
• Minimize identifiable cases of fraud/abuse and file the records.
• Achieve loss ratio target of 60%.
• Supervise Pre-authorization of scheduled and non-scheduled admissions within the set guidelines and carry out verification and medical Audit of claims/invoices before settlement.
• Negotiate/discuss professional fees as appropriate for each admission
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
• Prepare utilization reports of clients on a weekly, monthly and quarterly basis.
• Develop and implement a chronic condition management program for all our clients with chronic conditions.
• Carry out monthly review of reserves
• Provide monthly reports on admission cases
• Liaise with other medical schemes for purposes of evaluating medical risk
• Monitor that all amounts owed by third parties (e.g. contributing policies such as other medical policies, NHIF GPA, PA, travel, etc.) are fully recovered
• Participate in product presentation and health talks activities on a need basis
Skills
Case Management, Customer Service, Healthcare Auditing, Negotiations, People Management, Product Presentations, Supervision
Education
Diploma (Dip): Nursing (Required), Honours Degree (Hons): Nursing (Required)
Closing Date: 21 August 2022