Overall Job purpose
Reporting to the Assistant Manager, Medical the role holder shall process medical claims with a focus of providing clinical guidance in pharmacy, ensuring management of member benefits and cost control through designing strategies to ensure proper and cost effective care to members.
1.Audit and Verify outpatient, inpatient and reimbursement claims as per clinical guidelines and within the recommended guided tariffs.
2.Ensure regulatory control and drug management on all prescriptions ensuring advice on adverse drug reactions are suspected, or where potential on drug interactions existing and ensuring dosage and medicines are accurately prescribed.
3.Poly-Pharmacy – discourage poly-pharmacy by diligent challenging of prescriptions and suggesting better alternatives.
4.Generic substitution – Encourage use of generics where indicated as a method of reducing the organizations pharmaceutical expenditure.
5.Price guided tariffs- building of provider pricelists especially for bigger providers on average pharmaceutical expenditure.
6.Trend Analytics – Analysis of prescription patterns for providers and prescription drug use by members based on system-generated reports.
7.Audit independent pharmacies and pharmacies within the various hospitals.
8.Providing of novel strategies on reduction of the company’s pharmaceutical expenditure.
9.Develops and maintains networks within pharmaceutical sector, keeps updates on current practices, participates in professional societies
10.Good clinical acumen and keeps up to date with latest trends as provided by ministry of health and any other global bodies
11.Promptly and efficiently attend to customer queries and complaints perform any other duties as may be assigned from time to time.
12.Handle the 24 hr Helplines
Key Performance Measures
1.Saving the company money from wastage and exorbitant fees by providers.
2.Medical fraud mitigation
3.System support and integration on CPT coding
Knowledge, experience and qualifications required
1.Diploma in Pharmacy
2.At least two years of practise in a busy hospital set up or At least two years’ experience in medical claims processing in an insurance set up
1.Registered with the Pharmacy and Poison board.
2.Basic knowledge of insurance concepts
3.Knowledge of claims processes and procedures
4.Proficient in use of Microsoft office suites and packages
1.Learning & Researching
2.Working with people
3.Applying Expertise and Technology
4.Delivering Results and Meeting customer expectations
5.Following instructions & Procedures
6.Adhering to principles and values
1.Achieving personal work goals and objectives
2.Writing and Reporting
4.Planning & Organizing
5.Adapting and responding to change
6.Coping with pressures and setbacks
Friday, June 16, 2017