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Case Management Officer – (2500004H)
Job Purpose and Key responsibilities
Job purpose:
To oversee and coordinate all pre-authorization, admission, discharge, and care coordination activities, ensuring quality patient care while managing medical costs and provider relationships effectively.
Key responsibilities:
- Oversee medical case management and pre-authorizations.
- Ensure timely and appropriate approvals for inpatient and outpatient services.
- Collaborate with hospitals, TPAs, and providers to ensure quality care delivery.
- Monitor and track high-cost cases, chronic illnesses, and frequent claimants.
- Offer clinical guidance to underwriters and claims analysts on complex cases.
- Train and mentor staff and ensure process adherence.
- Maintain and update provider tariff lists and treatment protocols.
- Support fraud detection and provider performance reviews.
- Stay updated on industry trends, emerging risks, regulatory changes, and new technologies that could affect underwriting practices.
- Deliver on performance requirements as defined in the departments’ strategy map, balanced scorecard and Personal Scorecard.
- Perform any other duties as may be assigned from time to time
Knowledge, experience and qualifications required
Knowledge, experience and qualifications required:
- Bachelor’s Degree or Diploma in Nursing, Clinical Medicine, or related health field.
- 2-4 years’ experience in medical case management in the insurance sector.
- Strong clinical knowledge and experience managing medical claims or provider relations.
- Excellent communication and decision-making skills.
- Ability to work under pressure and coordinate with multiple stakeholders.
- Experience in customer, market and competitor understanding.
- Knowledge of Insurance regulatory requirements.
Primary Location
: Kenya-Nairobi-Nairobi
