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KEY DELIVERABLES

• Review medical claims for compliance with applicable policy guidelines

• Interact with clients, brokers and clinicians as needed, to resolve problems in manner that is legal, ethical and consistent with principals of the policy.

• Obtain medical information from providers telephonically during initial contact, during visits and follow up with written correspondence if necessary.

• Participate in care management meetings.

• During claim approval and second checking, confirm and ensure that accurate claim details are captured from the claim documents into ACTISURE by Registrars.

• Check and confirm membership validity and benefits (from the scheme benefits file)

• Handling of coverage enquiries with brokers, providers, members etc.

• Vet and confirm validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.

• Help in obtaining additional required information on claims from providers.

• Check and confirm any advice by the registrar on any relevant information noted on claims during claim approval or second checking.

• Liaising with the underwriting team on scope of cover for various schemes.

• Pre-authorize services that require prior approval from Jubilee Health.

• Manage 24-hour emergency help line.

• Any other duties that may be assigned by the Line Manager/ supervisor from time to time.