Company Overview

Afia Concept Claims Settling Agency (ACS) is a forward-thinking healthcare consulting firm operating in East Africa, with headquarters in Nairobi, Kenya. Established to bridge the gap between healthcare infrastructure and accessible, high-quality services, ACS offers end-to-end solutions in healthcare facility design, health financing advisory, digital health, and operational management.

Role Purpose

The Care Manager is a clinically trained professional at the heart of ACS's medical operations function. The role carries three interconnected responsibilities: adjudicating pre-authorizations with speed and clinical accuracy, negotiating medical costs with healthcare providers during active admissions and service delivery, and providing sound clinical guidance to members navigating the healthcare system.

A particularly critical aspect of this role is the ability to step down care — identifying situations where a member can receive equivalent quality of treatment at a more cost-effective facility or care setting, and facilitating that transition in a way that is clinically safe, member-centred, and clearly communicated. The Care Manager must balance advocacy for the member's health outcomes with stewardship of scheme sustainability.

The ideal candidate is a clinically confident, commercially aware healthcare professional — typically a registered nurse or clinician with managed care experience — who can make sound, defensible clinical decisions under time pressure while maintaining strong relationships with providers, members, and internal teams.

Key Accountabilities

Care Coordination & Case Management

• Coordinate and manage care plans for assigned members.
• Conduct clinical assessments and evaluate members' healthcare needs.
• Monitor admissions, ongoing treatment, referrals, and discharge processes.
• Facilitate continuity of care across healthcare providers and service points.
• Ensure timely escalation of critical and emergency cases.

Utilization Management

• Review treatment plans to ensure appropriateness, quality, and cost-effectiveness.
• Facilitate pre-authorizations and care approvals in accordance with clinical guidelines.
• Monitor healthcare utilization and identify opportunities for cost containment.
• Support interventions aimed at reducing unnecessary admissions and readmissions.

Provider & Stakeholder Engagement

• Liaise with healthcare providers to coordinate member care and treatment plans.
• Collaborate with internal teams to ensure seamless service delivery.
• Participate in provider engagements, case reviews, and clinical discussions.
• Foster positive relationships with members, providers, and other stakeholders.

Chronic Disease & Wellness Management

• Monitor high-cost, chronic, and complex medical cases.
• Support disease management and wellness initiatives.
• Promote preventive healthcare and member education programs.
• Guide members on available healthcare resources and treatment options.

Member Advocacy & Experience

• Act as an advocate for members throughout their healthcare journey.
• Provide guidance on benefit utilization and access to care.
• Address member concerns and facilitate timely resolution of service issues.
• Support initiatives aimed at improving member satisfaction and outcomes.

Clinical Quality & Compliance

• Ensure adherence to clinical protocols, policies, and regulatory requirements.
• Participate in clinical audits, quality reviews, and risk management activities.
• Monitor quality indicators and recommend improvement initiatives.
• Support implementation of evidence-based clinical practices.

Reporting & Documentation

• Maintain accurate and up-to-date clinical records and case documentation.
• Prepare care management, utilization, and case review reports.
• Track and report on key care management metrics and outcomes.
• Ensure confidentiality and proper management of member information.

Key Performance Indicators

• Member Care Coordination
• Quality of Clinical Outcomes
• Case Management Effectiveness
• Timeliness of Pre-Authorizations
• Member Satisfaction
• Care Plan Compliance
• Hospitalization and Readmission Management
• Utilization Management Effectiveness

Qualifications

• Bachelor's Degree or Diploma in Nursing, Clinical Medicine, Medicine, Pharmacy or a related healthcare field.
• Valid professional registration and licensing where applicable.

Added Advantage

• Professional qualification in AIIK, ACII, or Certificate in Insurance.
• Formal training in customer experience or call centre operations.
• Knowledge of medical scheme operations, SLAs, and healthcare provider management.
• Understanding of ISO Quality Standards and Data Protection Act compliance.

Experience

• Minimum of 2 years' experience in case management, utilization management, clinical care, managed care, medical insurance, or healthcare administration.
• Experience in a medical insurance, TPA, healthcare management, or managed care environment is preferred.
• Knowledge of healthcare benefits, pre-authorizations, and clinical protocols.

• Coordinate and manage care plans for assigned members.
• Conduct clinical assessments and evaluate members' healthcare needs.
• Monitor admissions, ongoing treatment, referrals, and discharge processes.
• Facilitate continuity of care across healthcare providers and service points.
• Ensure timely escalation of critical and emergency cases.
• Review treatment plans to ensure appropriateness, quality, and cost-effectiveness.
• Facilitate pre-authorizations and care approvals in accordance with clinical guidelines.
• Monitor healthcare utilization and identify opportunities for cost containment.
• Support interventions aimed at reducing unnecessary admissions and readmissions.
• Liaise with healthcare providers to coordinate member care and treatment plans.
• Collaborate with internal teams to ensure seamless service delivery.
• Participate in provider engagements, case reviews, and clinical discussions.
• Foster positive relationships with members, providers, and other stakeholders.
• Monitor high-cost, chronic, and complex medical cases.
• Support disease management and wellness initiatives.
• Promote preventive healthcare and member education programs.
• Guide members on available healthcare resources and treatment options.
• Act as an advocate for members throughout their healthcare journey.
• Provide guidance on benefit utilization and access to care.
• Address member concerns and facilitate timely resolution of service issues.
• Support initiatives aimed at improving member satisfaction and outcomes.
• Ensure adherence to clinical protocols, policies, and regulatory requirements.
• Participate in clinical audits, quality reviews, and risk management activities.
• Monitor quality indicators and recommend improvement initiatives.
• Support implementation of evidence-based clinical practices.
• Maintain accurate and up-to-date clinical records and case documentation.
• Prepare care management, utilization, and case review reports.
• Track and report on key care management metrics and outcomes.
• Ensure confidentiality and proper management of member information.

• Clinical accuracy
• Cost negotiation
• Clinical guidance
• Clinical decision-making
• Relationship management
• Case management
• Clinical assessments
• Treatment monitoring
• Continuity of care
• Escalation
• Utilization management
• Cost containment
• Provider liaison
• Team collaboration
• Chronic disease management
• Wellness initiatives
• Preventive healthcare
• Member education
• Member advocacy
• Benefit utilization
• Service issue resolution
• Clinical protocols
• Quality reviews
• Risk management
• Evidence-based practices
• Record keeping
• Report preparation
• Data management

• Bachelor's Degree or Diploma in Nursing, Clinical Medicine, Medicine, Pharmacy or a related healthcare field.
• Valid professional registration and licensing where applicable.
• Professional qualification in AIIK, ACII, or Certificate in Insurance (Added Advantage)
• Formal training in customer experience or call centre operations (Added Advantage)
• Knowledge of medical scheme operations, SLAs, and healthcare provider management (Added Advantage)
• Understanding of ISO Quality Standards and Data Protection Act compliance (Added Advantage)