Description

Bristol Park Hospital is a licensed healthcare provider that has been in operation for over 17 years, offering quality and affordable healthcare services in Nairobi, Kajiado, and Machakos counties. Guided by our “To be a world-class provider of quality, innovative, and accessible healthcare solutions,” we are committed to excellence in service delivery as well as patient care and safety.

We are seeking to recruit a highly skilled, experienced, and dynamic professional to join our team as Care Manager.

Responsibilities

Key Responsibilities

• Coordinate all inpatient and outpatient pre-authorization requests, extensions, and undertakings with payers.
• Ensure timely submission, follow-up, and approval of pre-authorizations and extensions within required turnaround times.
• Liaise with insurers, brokers, patients, and internal clinical teams to provide timely communication and clarification.
• Validate and manage undertakings, guarantee of payments, and financial exposures for admissions and specialized procedures.
• Ensure accuracy, completeness, and compliance of documentation and medical reports required by payers.
• Review service validity, membership, and benefit coverage against payer rules and clinical standards.
• Maintain accurate and structured records of authorization activities, including high-value cases.
• Coordinate inward and outward referrals, ensuring complete documentation and seamless continuity of care.
• Monitor trends, generate reports (daily, weekly, monthly), and identify gaps for continuous improvement.
• Support interdepartmental communication to enhance timely service flow and customer experience.
• Conduct capacity building for staff on appropriate billing and care coordination.
• Uphold compliance with regulatory, ethical, and care quality standards.

Qualifications

Qualifications & Experience

Essential

• Bachelor’s Degree in Nursing, Clinical Medicine, or related healthcare field.
• Minimum 3 years’ experience in:
  • Care coordination / Case management
  • Utilization review
  • Medical insurance liaison
  • Claims processing
  • Admission and discharge management
• Experience working with insurers, payers, and TPAs.
• Proven ability to interpret medical documentation, reports, and treatment plans.

Desirable

• Certification in Case Management, Utilization Management, or Health Insurance.
• Experience in referral coordination or clinical pathways.
• Experience in a multi-specialty hospital environment.
• Experience using HIS/EMR authorization modules.

• Coordinate all inpatient and outpatient pre-authorization requests, extensions, and undertakings with payers.
• Ensure timely submission, follow-up, and approval of pre-authorizations and extensions within required turnaround times.
• Liaise with insurers, brokers, patients, and internal clinical teams to provide timely communication and clarification.
• Validate and manage undertakings, guarantee of payments, and financial exposures for admissions and specialized procedures.
• Ensure accuracy, completeness, and compliance of documentation and medical reports required by payers.
• Review service validity, membership, and benefit coverage against payer rules and clinical standards.
• Maintain accurate and structured records of authorization activities, including high-value cases.
• Coordinate inward and outward referrals, ensuring complete documentation and seamless continuity of care.
• Monitor trends, generate reports (daily, weekly, monthly), and identify gaps for continuous improvement.
• Support interdepartmental communication to enhance timely service flow and customer experience.
• Conduct capacity building for staff on appropriate billing and care coordination.
• Uphold compliance with regulatory, ethical, and care quality standards.

• Care coordination
• Case management
• Utilization review
• Medical insurance liaison
• Claims processing
• Admission and discharge management
• Interpreting medical documentation
• Interpreting medical reports
• Interpreting treatment plans
• Communication
• Record keeping
• Report generation
• Staff training
• Regulatory compliance
• Ethical standards
• Care quality standards

• Bachelor’s Degree in Nursing, Clinical Medicine, or related healthcare field.
• Minimum 3 years’ experience in Care coordination / Case management, Utilization review, Medical insurance liaison, Claims processing, Admission and discharge management.
• Experience working with insurers, payers, and TPAs.
• Proven ability to interpret medical documentation, reports, and treatment plans.
• Certification in Case Management, Utilization Management, or Health Insurance (Desirable).
• Experience in referral coordination or clinical pathways (Desirable).
• Experience in a multi-specialty hospital environment (Desirable).
• Experience using HIS/EMR authorization modules (Desirable).