Purpose for the Job
The Optometrist will support the insurance healthcare function by evaluating optical approval requests and claims, ensuring clinical accuracy, managing provider relationships, driving cost-efficiency, and upholding service delivery standards. The role ensures timely approval of optical requests, reduction of fraud, and compliance with regulatory and internal audit requirements, while safeguarding client satisfaction and protecting the company's brand values.
Duties and Responsiblities
Client Service & Communication
Maintain high-quality communication with clients.
Provide accurate and timely responses to clients and service provider queries, ensuring alignment with service-level expectations.
Optical Claims & Approvals Management
Achieve and maintain an agreed optical approval Turnaround Times (TATs).
Conduct clinical validation of optical prescriptions, lens choices, and diagnoses to prevent fraud, inappropriate costing, or incongruent prescriptions.
Monitor and retain Optical TAT reports; share summaries and insights with management through the supervisor regularly.
Cost Management & Provider Negotiations
Drive annual cost savings through discount negotiations, detection of fraudulent plans or costing, and optimization of claim approvals.
Negotiate reduced optical costs.
Conduct service provider quality assurance audits annually, assessing clinical and commercial standards; prepare detailed post-audit recommendation reports.
Any other duty as may be assigned by the supervisor
Key Result Areas
Call Centre support - Customer service.
Cost Management / Cost containment .
Customer satisfaction.
Team Cohesion.
Key Competencies
Strong analytical and clinical assessment skills.
Excellent negotiation and provider relationship skills.
High attention to detail and accuracy.
Strong communication and client management capability.
Ability to work under pressure while maintaining service-level standards.
Ethical judgment and commitment to continuous improvement.
Knowledge And Skills Required
Optical background & knowledge.
Data Analytics & Computer Literacy.
Flexibility.
Teamwork.
Time Management .
Excellent verbal and written communication skills. Solution Oriented
Valid professional practicing license.
Minimum 2 years' experience in optical practice or claims assessment (insurance experience is an added advantage).
Strong knowledge of optical products, clinical diagnostics, claims processes, and fraud detection.
Proficiency in healthcare management systems and MS Office Suite.
Professional and Academic Qualifications
Bachelor's degree or Diploma in Optometry or Ophthalmic Clinical Sciences.