Overall Purpose of the Job

Reporting to the Supervisor Case Management, the Care Manager will ensure quality and efficiency in case management as well provide quality medical service delivery to all our clients.

Key Responsibilities

• Handling the emergency office lines and responding to clients queries as they arise on a 24/7 basis.
• Negotiate rates and treatment protocols with providers with a view to keeping claims below 60%.
• Implement all care management protocols and ensure that all procedures of the company are adhered to in adjudication resulting in accurate medical assessment, interpretation and intervention.
• Manage the workflow process from pre-authorization, case management and necessary system updates for claim processing.
• Implement and oversee the pre-existing & chronic disease management program, follow up of clients after discharge from hospital with a view of cost management for the company and the clients.
• Daily follow-up (Calling/Visits) of all hospitalized clients, to provide advice on coverage and care, manage end to end admission and discharge process of all clients.
• Prepare daily case management reports on admissions with detailed analysis for discussion and planning with action that favor the company as per the scheme rules and guidelines.
• Report on all admissions and issue relevant communication/letters for approved cases to all parties involved.
• Monitor cost of treatment at the various providers and advise underwriting department, and management on the most cost-effective providers to use.
• Communicate in a timely manner all rejections, deductions or declines to service providers and members with documentary evidence of the same.
• Clients presentations and member education on wise benefits utilization & risk management.
• Liaising with our underwriting section on scope of cover for various schemes.

Requirements

Education, Experience & Competencies

• Holder of a Bachelor’s degree preferably in Nursing or Clinical Medicine.
• Possess at least 5 years relevant experience.
• Demonstrate a good understanding of case management.
• Proficient in the use of Microsoft office suite and packages.
• High level of Emotional Intelligence.
• Excellent Communication and Interpersonal skills.
• Customer focused with strong problem solving skills
• Professional Insurance Certification (COP or Diploma in Insurance) is an added advantage
• Good interpersonal skills and a team player

Why Join Us:

• A dynamic and supportive work environment.
• Opportunities for professional growth and career advancement.
• Competitive salary and benefits package.
• Being part of a leading insurance company committed to innovation and excellence.