Corporate Health Document & Data Operations Associate (Medical Vetting) at Britam

Job Purpose

Control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.

Key responsibilities

• Process all reimbursements as per SLA
• Process all claims from service providers as per SLA
• Process all reconciliation service provider invoices are reviewed and shared as per SLA 
• Accurate and timely processing of client requests
• Manage escalation reports of recurrent issues vis-à-vis agreed Service Level Agreements.
• Escalate quality issues to Operations manager for management.
• Implement the customer experience strategy in the respective business divisions
• Investigate and respond to all internal and external customer enquiries promptly.
• Escalate complex queries to the appropriate functional area
• Maintain regular internal (to staff) and external (to customers) communication on Customer Service matters.
• Investigate and respond to all customer enquiries promptly.
• Carry out customer and product related document processing
• Respond to customer queries in a professional manner
• Make customers’ experiences better by ensuring customer satisfaction
• Ensure high standards of Customer Service are maintained in all at level
• 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 a 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

Knowledge, experience and qualifications required

• 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 added advantage
• 2-3 years’ experience in medical claims or case management position