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.

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

• 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

• Stakeholder management
• Clinical knowledge
• Medical report interpretation
• Treatment plan interpretation
• Health insurance policy understanding
• Benefit understanding
• Scheme structure understanding
• Case management
• Utilization review
• Analytical thinking
• Decision-making
• Attention to detail
• Accuracy in documentation
• Benefit adjudication
• Communication skills
• Interpersonal skills
• Customer service orientation
• Empathy
• Professionalism
• Negotiation skills
• Relationship management
• Compliance knowledge
• Medical ethics knowledge
• Healthcare regulations knowledge
• Fraud, waste, and abuse mitigation
• Knowledge of emerging trends in health insurance
• Knowledge of diagnostic procedures in Kenya
• Problem-solving skills
• Emotional intelligence
• Integrity
• Trustworthiness
• Dependability

• 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.