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 to securing savings for the company.
• 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.

Education, Experience & Competencies

• Holder of a Bachelor’s degree preferably in Nursing,
• Have at least 5years 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.