Reporting to the Senior Risk Health and Wellness Officer
The main responsibilities of the job are:
- Reviewing claims to identify errors, fraud, and trends.
- Pre-authorizing hospital admissions and monitoring member benefits.
- Registering and following up with patients enrolled in the chronic disease management program.
- Conducting workplace-based wellness programs for corporate clients.
- Investigating service providers and members with suspicious claiming patterns.
Qualifications:
- Diploma in Nursing (Please note that a Nursing background is a must).
- Diploma or Degree in Insurance and Risk Management, or equivalent, is an added advantage.
- Diploma in Theatre Nursing and/or Midwifery is an added advantage.
Ideal Candidate must:
- Have at least 2 years’ experience in claims investigations, case management, and implementation of wellness programmes within a medical aid environment.
- Possess excellent investigative, problem-solving, and decision-making skills.
- Demonstrate a strong client focus.
- Have good written and verbal communication skills.
- Be a person of integrity, with the ability to handle sensitive information confidentially and transparently.