Clinical Case Manager

Reporting to the Manager Clinicals, the role holder will be responsible for control and managing of the policy cycle through pre-authorization and case management, to ensure quality and cost effective care.

1. Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
2. Interact with clients and service providers to ensure that the care is given within policy guidelines.
3. Review medical reports and claims for compliance with set guidelines.
4. Liaise with underwriters on scope of cover for the various schemes.
5. Ensure that medical scheme members are attended to round the clock with support from 24 hour call centre.
6. Poly-Pharmacy – discourage poly-pharmacy by diligent challenging of prescriptions and suggesting better alternatives.
7. Generic substitution – Encourage use of generics where indicated as a method of reducing the organizations pharmaceutical expenditure.
8. Delegated Authority: As per the approved Delegated Authority Matrix.
9. Prepare periodic reports for management on medical claims.
10. Ensure claims are processed within the stipulated time.
11. Perform any other duties as may be assigned from time to time.

1. Diploma/Degree in Nursing or Diploma in clinical medicine or Diploma in Pharmacy.
2. Understanding of insurance concepts.
3. Professional qualification in FLMI, ACII and IIK would be an added advantage.
4. 3-4 years’ experience in case management.