Case Management Officer Job in Kenya

Job Purpose:

Controlling and Managing policies through case management to ensure quality and cost effective care, client service, provider management, processing and payment of claims.

Key Responsibilities:

  • Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
  • Interact with clients and service providers to ensure that the care is given within policy guidelines.
  • Review medical reports and claims for compliance with set guidelines.
  • Liaise with underwriters on scope of cover for the various schemes.
  • Ensure that medical scheme members are attended to round the clock with support from 24 hour call centre.
  • Discourage poly-pharmacy by diligently challenging of prescriptions and suggesting better alternatives as per medical practice.
  • Encourage use of generics and cost effective quality drugs where indicated as a method of reducing the organizations pharmaceutical expenditure.
  • Review documents and pertinent requirements regarding claims from providers and clients.

  • Ensure that the claim made by the claimant is complete in form and complies with the documentary requirements of an insurance claim.
  • Management of relationships with clients, intermediaries and service providers.
  • Verification and audit of outpatient and inpatient claims to ensure compliance and mitigate risk.
  • Advice claimants regarding basic matters about their insurance coverage in relation to the insurance claim
  • Respond to both internal and external claims inquiries concerning claims process, service providers, and the filing/completion of proper forms.
  • Record all claims transactions.
  • Prepare claims registers for claims meetings and update the various claims reports.
  • Track and follow up on receipt of necessary documents.
  • Delegated Authority:  As per the approved Delegated Authority Matrix.
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Knowledge, Experience And Qualifications Required

  • Degree in Bachelor of Science in Nursing Sciences from a recognized university.
  • Professional Nursing qualification KRCHN licensed by Nursing council of Kenya.
  • At least two-year experience in case management and claims processing.

Technical/ Functional competencies:

  • Knowledge of insurance regulatory requirements.
  • Knowledge of insurance products.
  • Sales and marketing management skills.

How To Apply

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