RESPONSIBILITIES:
Care Management

• Active Care & Authorization Oversight: Monitors patient care in real time—tracking length of stay, clinical necessity, and treatment plans while securing pre-authorizations and limit extensions on scheme portals before charges accumulate.
• Proactive Financial & Scheme Alignment: Inform clinical teams and patients early on policy exclusions, limits, and co-pays to set clear expectations and prevent billing disputes at discharge.
• Liaison & Care Transition: Acts as the primary clinical link between attending doctors, hospital staff, and corporate/insurance case managers. Ensures smooth, fully coded billing clearance at discharge.
• Utilization & Quality Assurance: Audits treatment patterns to curb over-utilization (unnecessary drugs or duplicate tests) and ensures care adheres to standard clinical protocols.

Verification of claims before processing for dispatch to corporate clients.

• Check if diagnosis is matching drugs issued and investigations.
• Highlight and identify exclusions from corporate (in terms of prescribed drugs) and implement ways of reducing such rejections before claims are dispatched.
• Signing on behalf of the doctor where the signature is missing.
• Filling of claim forms on invoices without claim forms.
• Work with the dispatch section to verify claims before they are dispatched.

Reconciliation on Rejections regarding clinical issues and other returned invoices.

• Monitoring invoice returns and taking appropriate action within a week from the date of return on clinical issues and any query.
• Take a lead in ensuring the reasons for returns are well addressed to avoid future recurrence.
• Preparing Rejection analysis on clinical issues and monthly reports as a tool to guide the institution on the status of control.
• Work with the Debtors team to review all the Clinical issues within the reconciliation to sign off for the agreed period with corporate clients.
• Facilitate closures to all rejected invoices on medical issues.

ICD-10 coding of claim forms

• Develop proficiency in and familiarize oneself with the ICD-10 coding system and coding tools.
• Develop proficiency in and familiarize oneself with insurance scheme platforms, including Smart, Slade, LCT, M-TIBA, and other relevant platforms.
• Develop proficiency in and familiarize oneself with CareWeb ICD Voucher Wise ICD entry and coding procedures.
• Ensure 100% of insurance claim forms requiring ICD-10 coding in CareWeb ICD Voucher Wise are collated, accurately coded, and completed within the stipulated turnaround time.
• Ensure 100% of insurance claim forms requiring ICD-10 coding on insurance scheme platforms are collated, accurately coded, and completed within the stipulated turnaround time.
• Aggregate, review, and follow up on claims with missing or incomplete diagnoses on a daily and weekly basis to facilitate timely and accurate coding and submission.
• Participate in all team efforts as departmental needs arise.
• Perform other duties as may be assigned by the Manager.

The requirements

• Diploma in Clinical Medicine or equivalent from a recognized institution
• Current practicing Certificate
• Membership registration to the relevant professional body.
• A minimum of 3 years’ relevant experience in a busy Hospital or Insurance
• Results-driven, ethical and adaptable professional with a strong service and stakeholder focus.
• Strong integrity with a sensitivity to manage confidential information.