Call Center-Case Management Nurse (oldmutual)

Job Description

Lets Write Africa's Story Together!

Old Mutual is a firm believer in the African opportunity and our diverse talent reflects this.

Job Description

KEY RESPONSIBILITIES:

• Verification and vetting all medical claims prior to registration in E-Oxygen.
• Extract and carry out Doctor opinion on all claims registered in E-Oxygen.
• Participate in carrying out/conducting claims quality assurance on a monthly basis.
• Processing of all medical claims payment as per agreed procedures, timelines & policy.
• Negotiating professional / procedure fees with service providers and ensuring the fees are within the agreed/approved rates.
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• Issuing of reimbursement cheques and keeping records promptly.
• Pre-authorization of services to the hospital and issuing LOU/LOD as appropriate
• Make recommendations on cover design aspects with high losses from claims verification knowledge.
• Give prompt feedback to the underwriting team on claims that would require future underwriting interventions.
• Identify cases of over-pricing, fraud and over utilization
• Case management and authorizations (benefit utilization management and Hospital Visits)
• Responding to various queries/ communication from brokers, agents, doctors, clients and hospitals regarding medical claims.
• Timely generation of reports for settlement purposes.
• Participate actively in executing the following case management activities accurately & timely within the agreed TAT – (claims vetting, doctor opinion, member education, emergency medical evacuation, hospital visits, Tele-medicine, pre-authorizations, approvals etc.).

Provides a service as a temporary employee covering many fields.

Skills

Competencies

Education

Closing Date

The Old Mutual Story!