Job Summary

The case manager will proactively collaborates with health insurance clients, intermediaries, medical service providers, and internal teams to facilitate access to quality, safe, timely, effective, and cost-efficient healthcare services while staying continuously updated on industry innovations, challenges, and emerging trends to deliver top-notch service. Success in this vital role is directly measured through critical performance metrics, including high levels of customer satisfaction, effective cost containment, strict adherence to medical protocols, rapid turnaround times (TATs), and full compliance with all relevant company policies, legal guidelines, and regulatory requirements.

Responsibilities

• Through due diligence, issue undertakings in line with the policy provisions. Likewise, for declines or part approvals, ensuring that the decisions are accurate and a correct interpretation of the policy.
• Review patient’s history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.
• Pre-authorize admission, discharges, scheduled and emergency medical cases, issue timely responses as per policy benefits and company guidelines.
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.
• Conduct admitted patients visits and daily follow-ups, ensuring they receive quality and cost-effective care
• Ensure appropriate Turnaround Time is adhered to in issuing approvals, letters of undertaking and correspondence.
• Collaborate with Brokers/ Agents/ Corporates/Customer relations by communicating and updating them with necessary admission claim decisions on a timely basis.
• Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is timely, ethical and consistent with the First Assurance policy, applicable legal and regulatory requirements.
• Negotiating with providers, doctors, hospitals on cost, tariffs, discounts, pre-agreed rates, packages, fixed cost model
• Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
• Collaboration with Cross-Functional Teams: Working closely with various departments like provider relations, call center, claims, underwriting, audit to address customer needs and provide comprehensive solutions.
• Undertaking presentations and member education on wise utilization & risk management
• Daily review of admitted patients’ treatment plans, monitor improvements, bill escalation and provide guidance on coverage, inform intermediaries and ensure care coordination.
• Follow through and resolve escalated customers and provider queries and complaints in time and advise them on outcome and the details of the medical product.
• Advise members on how best to utilize their benefits by recommending cost effective facilities and cheaper options e.g., maternity packages, chronic management.
• Generate, recommend and implement preventive care program through health talks, wellness and the chronic disease management program CDMP.
• Process Improvement and Innovation: Identifying areas for process enhancement, suggesting improvements and implementing innovative solutions to streamline operations
• Send weekly and monthly report on admissions, exceptional claims, long stay, savings amongst others.
• Observe confidentiality of client information and compliance with the Data Protection Act
• Performs all other tasks as assigned by line manager.

Knowledge Management

• Improve technical knowledge through self-learning or training including mandatory Continuous Professional Education requirements.
• Share knowledge with colleagues and peers in the business.
• Develop and enhance learning through seeking coaching, training and continual feedback

Reporting

• Sending daily admissions reports to clients; Brokers/Agents/ company Human resource managers.
• Prepare and compile section reports on daily, weekly and monthly basis and forwards to the management.

Relationship management

• Develop and maintain relationships with colleagues and clients; Brokers/Agents/ company Human resource managers.

Education, Experience Required and Competencies:

Technical Skills: Proficiency Microsoft Office Suite

Education: Bachelor’s Degree/Diploma in Nursing (KRCHN)/ Clinical Medicine/ Health Management or in a related field.

Experience Level: Minimum 2 years of clinical experience and 1 year case management experience

Soft Skills: Excellent communication skills, empathy, negotiations, problem-solving abilities, adaptability, excellent communication and a customer-centric approach.

Industry Knowledge: Understanding of insurance policies, regulations, compliance and standards

Licensed by relevant statutory regulator in his/her respective medical field.

Member of relevant professional medical association in good standing.

• Through due diligence, issue undertakings in line with the policy provisions. Likewise, for declines or part approvals, ensuring that the decisions are accurate and a correct interpretation of the policy.
• Review patient’s history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.
• Pre-authorize admission, discharges, scheduled and emergency medical cases, issue timely responses as per policy benefits and company guidelines.
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.
• Conduct admitted patients visits and daily follow-ups, ensuring they receive quality and cost-effective care
• Ensure appropriate Turnaround Time is adhered to in issuing approvals, letters of undertaking and correspondence.
• Collaborate with Brokers/ Agents/ Corporates/Customer relations by communicating and updating them with necessary admission claim decisions on a timely basis.
• Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is timely, ethical and consistent with the First Assurance policy, applicable legal and regulatory requirements.
• Negotiating with providers, doctors, hospitals on cost, tariffs, discounts, pre-agreed rates, packages, fixed cost model
• Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
• Collaboration with Cross-Functional Teams: Working closely with various departments like provider relations, call center, claims, underwriting, audit to address customer needs and provide comprehensive solutions.
• Undertaking presentations and member education on wise utilization & risk management
• Daily review of admitted patients’ treatment plans, monitor improvements, bill escalation and provide guidance on coverage, inform intermediaries and ensure care coordination.
• Follow through and resolve escalated customers and provider queries and complaints in time and advise them on outcome and the details of the medical product.
• Advise members on how best to utilize their benefits by recommending cost effective facilities and cheaper options e.g., maternity packages, chronic management.
• Generate, recommend and implement preventive care program through health talks, wellness and the chronic disease management program CDMP.
• Process Improvement and Innovation: Identifying areas for process enhancement, suggesting improvements and implementing innovative solutions to streamline operations
• Send weekly and monthly report on admissions, exceptional claims, long stay, savings amongst others.
• Observe confidentiality of client information and compliance with the Data Protection Act
• Performs all other tasks as assigned by line manager.

• Proficiency Microsoft Office Suite
• Excellent communication skills
• Empathy
• Negotiations
• Problem-solving abilities
• Adaptability
• Customer-centric approach

• Bachelor’s Degree/Diploma in Nursing (KRCHN)/ Clinical Medicine/ Health Management or in a related field.
• Licensed by relevant statutory regulator in his/her respective medical field.
• Member of relevant professional medical association in good standing.