EMC Medical Claims Associate 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

• 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
• Perform any other duties as may be assigned from time to time.

Key Performance Measures

• As described in your Personal Score Card

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.
• 5-8 years’ experience in case management two of which should be in a supervisory position

Leadership category responsibility framework (Core Competencies) 

Emerging Leaders in Britam need to:

• Plan, direct and apply efficiencies and resources in order to optimise output and profitability against time, cost and team targets;
• Effectively communicate strategic and operational departmental goals and objectives to peers and others in order to ensure proper implementation;
• Ensure that department priorities are adhered to and effectively communicated;
• Ensure competent and effective people resources through appropriate coaching, development and people supervision as appropriate;
• Embody a high performance, proactive culture;
• Effectively ensure the adherence to key performance areas, deadlines and goals in order to optimise operational effectiveness;
• Effectively communicate resource needs, possible opportunities and achievements to management in order to aid them in their decision-making;
• Effectively set and monitor priorities and objectives for more junior staff;
• Understand and communicate objectives in relation to the larger organisational impact;
• Effectively disseminate knowledge within the correct context, towards subordinates as well as management;
• Appropriately model the company values while setting the pace and energy for delivering;
• Effectively manage and communicate change within the department in order to increase staff and process effectiveness;
• Provide access to accurate and consistent information and services across all channels; 
• Ensure a seamless experience for clients;
• Improve service delivery for clients;
• Engage in continuous brand building to become the trusted partners to clients.

Technical/ Functional competencies

• Knowledge of insurance regulatory requirements
• Knowledge of insurance products
• Sales and marketing management skills.

Closing: 20 August 2022