Primary Responsibilities:
Care Management, handling Outpatient, Optical and Dental preauthorizations, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns and managing the 24-hour emergency line.
Key Responsibilities:
Care Management - Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise, for declines, ensuring that the decisions are accurate and a correct interpretation of the policy
Ensure appropriate Turnaround Time is adhered to in issuing approvals.
Seeking medical clarifications including medical reports, copies of investigation reports from providers as per standard procedure.
Broker/customer relations by communicating all necessary claim decisions to clients on a timely basis.
Work with the claims team and providing on any information required in the claims submitted in cases where further information provided changes the position undertaken previously on the claim.
Interacting with clients, brokers and providers as needed, to resolve problems in a manner that is legal, ethical and consistent with the principles of the policy.
Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost and average cost agreements.
Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
Liaising with underwriting department on scope of cover for various schemes
Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc
Managing the 24-hour emergency helpline
Implementation of strategic initiatives for the department and recommendations by claims QA committee.
Achieve an NPS scope on all customer service indicators.
Compliance to internal business processes, IRA Regulations/guidelines and adherence to work Ethics for the department
Client presentations and member education on wise utilization & risk management
Support the care management team to ensure all the deliverables are met within the given turnaround time
Skills and Competencies Required
Health Benefits Plan Management
Policy Interpretation
Customer Service and Focus
Responsibility & commitment
Team Spirit
Excellent communication
Ability to multi-task
Strong negotiation and decision-making skills
Knowledge & Work Experience
At least 2 years' case management or relevant experience.
Demonstrated knowledge of managing admissions and discharges
Academic and Professional Qualifications required
Bachelor's degree in nursing or clinical medicine