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Care Officer – Case Management
About the position
Job Summary:

The primary purpose of the Care officer role is to deliver clinical oversight and case management for insured members requiring hospitalization. The role is responsible for ensuring that members receive medically appropriate, high-quality, and cost-effective care, while also safeguarding the financial sustainability of the medical scheme. This includes evaluating pre-authorizations, monitoring inpatient admissions and coordinating with healthcare providers. The position requires strong clinical acumen, a deep understanding of medical insurance operations, benefit structures, and regulatory requirements.

Duties and Responsibilities:

Ensure proper care and treatment of patient within acceptable protocols to mitigate overuse of cover by member / provider
Vet and review claim documents with the goal of determining the validity as reported in the claim form to determine eligibility including validity and benefits as per policy guidelines
Prepare daily reports of admissions in the various service providers
Attend to all our customers and ensure complicated and disputed cases at the call centre are escalated and resolved within the agreed timelines.
Undertake timely claims processing within the timelines of provider payment schedules
Obtain additional required information on claims from providers, brokers or clients by going through pre-authorization forms and scrutinize forms for correct diagnosis
Undertaking patient visits to ensure quality service, correct treatment and eligibility where required explain the medical terms of cover or where queried
Inform the provider manager / provider management team on any anomalies of provider service / quality concerns
Review and resolution of complex cases and provide appropriate clinical expertise on diagnosis / treatment within policy coverage including where clients require medical guidance and escalate where necessary
Interact with clients, brokers and clinicians as needed, informing them as necessary admission claim decisions on a timely basis, to resolve problems within the guidelines of the policy and escalate where necessary
Liaise with underwriting section on clarity of scope and omission
Provide support in the preparation of client presentations and member education on wise usage of cover
Academic and Professional Qualifications

Bachelor’s degree/Diploma in nursing or clinical medicine, or a related field.
Professional Nursing qualification KRCHN licensed by Nursing council of Kenya.
Relevant certifications in case management, healthcare management, or clinical specialties.
Experience

At least 3 years’ case management experience in a medical insurance environment, with demonstrated expertise in inpatient care coordination, insurance benefit administration, policy interpretation, and pre-authorization processes.
Demonstrated knowledge of managing admissions and discharges
Experience in provider engagement will be an added advantage.
Technical Competencies

Experience in managing stakeholders in the health insurance services ecosystem
Clinical knowledge and ability to interpret medical reports and treatment plans
Understanding of health insurance policies, benefits, and scheme structures
Strong case management and utilization review skills
Analytical thinking and sound decision-making based on clinical and policy guidelines
Attention to detail and accuracy in documentation and benefit adjudication
Excellent communication and interpersonal skills for engaging clients, providers, and internal teams
Customer service orientation with empathy and professionalism
Negotiation and relationship management skills with service providers and stakeholders
Knowledge of compliance requirements, medical ethics, and healthcare regulations
Ability to identify and mitigate fraud, waste, and abuse in claims
Knowledge of emerging trends and procedures in health insurance services management
Working knowledge of diagnostic procedures within the Kenya healthcare system
 

Behavioural Competencies

Strong customer service
Strong analytical and problem-solving skills
Results driven and action oriented
Collaborative team player
Strong attention to detail
Agile mindset with demonstrated ability to manage tasks with competing deadlines
High degree of emotional intelligence, integrity, trust and dependability
Ability to work independently as well as part of a team