Madison Group Limited is a locally owned financial services holding company that specializes in Insurance and wealth management services. The Group comprises of Madison Life Assurance Kenya Limited, Madison General Insurance Kenya Limited, and Madison Investment Managers Limited. Madison Life Assurance Kenya was originally incorporated under Kenyan Laws in 1988 as Madison Insurance Company Limited (MICK) after a successful merger between Crusader Plc (1974) and Kenya Commercial Insurance Corporation.

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Care Manager – Kitale Branch

Job Type

Full Time

Qualification

BA/BSc/HND

Experience

2 years

Location

Kitale

Job Field

Insurance

Primary Responsibilities:

Care Management, handling Outpatient, Optical and Dental preauthorizations, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns and managing the 24-hour emergency line.

Key Responsibilities:

Care Management – Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise, for declines, ensuring that the decisions are accurate and a correct interpretation of the policy

Ensure appropriate Turnaround Time is adhered to in issuing approvals.

Seeking medical clarifications including medical reports, copies of investigation reports from providers as per standard procedure.

Broker/customer relations by communicating all necessary claim decisions to clients on a timely basis.

Work with the claims team and providing on any information required in the claims submitted in cases where further information provided changes the position undertaken previously on the claim.

Interacting with clients, brokers and providers as needed, to resolve problems in a manner that is legal, ethical and consistent with the principles of the policy.

Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost and average cost agreements.

Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases

Liaising with underwriting department on scope of cover for various schemes

Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc

Managing the 24-hour emergency helpline

Implementation of strategic initiatives for the department and recommendations by claims QA committee.

Achieve an NPS scope on all customer service indicators.

Compliance to internal business processes, IRA Regulations/guidelines and adherence to work Ethics for the department

Client presentations and member education on wise utilization & risk management

Support the care management team to ensure all the deliverables are met within the given turnaround time

Skills and Competencies Required

Health Benefits Plan Management

Policy Interpretation

Customer Service and Focus

Responsibility & commitment

Team Spirit

Excellent communication

Ability to multi-task

Strong negotiation and decision-making skills

Knowledge & Work Experience

At least 2 years’ case management or relevant experience.

Demonstrated knowledge of managing admissions and discharges

Academic and Professional Qualifications required

Bachelor’s degree in nursing or clinical medicine

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• Care Management, handling Outpatient, Optical and Dental preauthorizations, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns and managing the 24-hour emergency line.
• Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise, for declines, ensuring that the decisions are accurate and a correct interpretation of the policy
• Ensure appropriate Turnaround Time is adhered to in issuing approvals.
• Seeking medical clarifications including medical reports, copies of investigation reports from providers as per standard procedure.
• Broker/customer relations by communicating all necessary claim decisions to clients on a timely basis.
• Work with the claims team and providing on any information required in the claims submitted in cases where further information provided changes the position undertaken previously on the claim.
• Interacting with clients, brokers and providers as needed, to resolve problems in a manner that is legal, ethical and consistent with the principles of the policy.
• Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost and average cost agreements.
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
• Liaising with underwriting department on scope of cover for various schemes
• Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc
• Managing the 24-hour emergency helpline
• Implementation of strategic initiatives for the department and recommendations by claims QA committee.
• Achieve an NPS scope on all customer service indicators.
• Compliance to internal business processes, IRA Regulations/guidelines and adherence to work Ethics for the department
• Client presentations and member education on wise utilization & risk management
• Support the care management team to ensure all the deliverables are met within the given turnaround time

• Health Benefits Plan Management
• Policy Interpretation
• Customer Service and Focus
• Responsibility & commitment
• Team Spirit
• Excellent communication
• Ability to multi-task
• Strong negotiation and decision-making skills

• Bachelor’s degree in nursing or clinical medicine