Medical Officer at CIC Insurance

PURPOSE:

Responsible for ensuring accurate capture of inpatient admissions with adherence to CIC policy guidelines, monitoring benefits utilization of various schemes and making clinical decisions in line with the policy.

PRIMARY RESPONSIBILITIES:

• Evaluate all admission notifications before giving any financial undertaking
• Give financial undertaking on eligible cases with reference to the policy guidelines and benefits limits.
• Ensure the hospital /doctors adhere to CIC admission procedures/cost guidelines
• Identify cases for potential risks /long stay or complex and notify the relevant stake holders in good time.
• Customer engagement through hospital visits and calls for all admitted patients to monitor progress clinically/financially and prepare daily feedback reports.
• Evaluate and facilitate referral cases and scheduled surgeries promptly once pre-authorization request have been received.
• Assess all bills during admission and on discharge to ensure treatment is consistent with illness declared and cost for items are also in line with the market rate/CIC rates.
• Promptly request for medical/progress report where applicable, review and make clinical decisions in line with CIC policy.
• Monitor benefits utilization and where necessary communicate to the contact person of scheme.
• Negotiate cost with doctors and hospital.
• Follow up on NHIF approvals for surgical procedures.
• Referring client to low cost providers for inpatient care, radiology services or pathology services to an effort to manage cost while maintaining quality of care.
• Daily follow up on the progress of all admitted patients with doctors to evaluate progress, promote continuity of care and ensure improved health outcomes.
• Daily updates on patient condition to the scheme contacts and intermediaries.
• Review and prudent decision making on all overseas referrals
• Involved in Identifying and recruiting high-quality and cost effective healthcare providers.
• Creating and updating personalized care plans for patients.
• Putting in place cost management initiatives for all the inpatient to manage IP average costs
• Vetting all inpatient reimbursements to ensure they are in line with policy and benefit allocation
• Maintain admission records for different schemes.
• Claims analysis and clinical recommendations to address health seeking behaviors and ensure cost management while maintaining good outcomes.
• Implementation of Chronic Disease Management and wellness program

PERSON SPECIFICATIONS

Academic Qualifications

• Bachelor’s degree in Medicine.

Professional Qualifications

• Registered by Medical Board.

Experience

• Post internship experience of two (2) years.

 Skills and Attributes

• Advanced ability to ensure the highest standards in patient care and compliance with healthcare regulations.
• Ability to keep abreast of advancements in the field of specialization.
• Proficient in MS Office
• Excellent interpersonal, analytical, communication, and negotiation skills.
• Experience in medical insurance and health claim analysis is an added advantage.

If you have the aforementioned professional and academic qualifications and you are ready to execute the above mandate.