Job Ref. No: JHIL180

Role Purpose

The primary purpose of the Case Manager, Active Case Management is to deliver end-to-end clinical oversight and case management for insured members requiring hospitalization. The role is responsible for ensuring that members receive medically appropriate, high-quality, and costeffective 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.

Main Responsibilities
Operational

• Make timely decisions on inpatient pre-authorizations and undertakings in line with policy limits and clinical appropriateness.
• Review medical reports and documents to determine coverage and need for treatment.
• Manage 24-hour nurse line operations on a shift basis to support round-the-clock member needs.
• Verify membership eligibility and assess scope of benefits using scheme-specific records.
• Vet and authorize inpatient services
• Liaise with underwriting and provider relations teams to ensure accurate interpretation of benefits and scheme terms.
• Provide responses to client, provider, and internal queries regarding coverage, claim status, or treatment approvals.
• Maintain accurate records for all case-related transactions.
• Track turnaround time for all approvals and ensure timely processing and communication of decisions.
•  Support the team in meeting departmental SLAs and KPIs.

Corporate Governance

• Ensure all inpatient authorizations and claims are reviewed and processed in strict adherence to policy provisions and regulatory guidelines.
• Conduct thorough due diligence on approvals and declines, documenting all decisions accurately and consistently.
• Vet all undertaking requests for completeness, validity, and compliance with insurance documentation standards.
•  Audit inpatient and outpatient claims to identify inconsistencies or potential fraud.
• Confirm service validity against treatment given, provider rules, and cost thresholds.
• Ensure all care management practices align with national healthcare regulations and medical ethics.

Key Competencies

• 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

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.

Relevant Experience

• Minimum of two (2) years of relevant experience in a similar or equivalent role within a medical insurance environment, with demonstrated expertise in inpatient care coordination, insurance benefit administration, policy interpretation, and pre-authorization processes. Experience in provider engagement will be an added advantage.