Job Description
Job Ref. No. JHIL030
Position: Care Manager
Employment Terms: 1 Year Contract
We currently have an exciting career opportunity for a Care Manager within Jubilee Health Insurance Limited. The position holder will report to the Senior Care Manager and will be based at the Head office in Nairobi
Role Purpose
The role holder will be responsible for visiting patients at the various service providers, providing professional guidance on policy matters,
ensuring comfort and assistance of patient by the service provider, and communicating with providers, clients and brokers on a timely basis for any rejections or relevant concerns
Main Responsibilities
1. Obtaining daily reports of admissions in the various service providers
2. Broker/customer communications by communicating as necessary admission claim decisions on a timely basis
3. Care Management - Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise for
declines, ensuring that the decisions are accurate
4. Fraud mitigation – Implementing fraud mitigation strategy for the company.
5. Provider relationship management – Ensuring strong provider relationships to enhance provider and customer experience.
6. Visiting of patients at the various service providers, obtaining details of patients to confirm that admitted members are the
eligible policy holders/ dependents
7. Confirming that the treatment the member is given is covered by the policy purchased
8. Ensuring that the medical reports in the hospital are accurate and reflective of what is provided to the insurer and also
confirm what the member understands or communicates
9. Ensuring proper care and treatment of patient within acceptable protocols without wastage by member/ provider
10. Reviewing medical pre-authorizations for compliance with applicable policy guidelines and giving guidance to the other care
management team on any information collected during the visits to the hospitals
11. Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is legal, ethical and consistent
with the principles of the policy
12. Obtaining medical information from providers with written correspondence if necessary.
13. Checking and confirming membership validity and benefits (from the scheme benefits file)
14. Handling of coverage enquiries with brokers, providers, members.
15. Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment
given, adherence to provider panel rules and cost of treatment
16. Obtaining additional required information on claims from providers, brokers or clients
17. Liaising with our underwriting section on scope of cover for various schemes
18. Assisting in conducting provider audits wherever necessary.
19. Client presentations and member education on wise utilization & risk management
20. Managing the 24-hour emergency helpline
Key Competencies
1. Passionate, Goal driven and results oriented.
2. Strong organizational and analytical skills.
3. Strong Problem-solving skills.
4. Communication skills
5. Team Spirit
6. Strong interpersonal & relations skills
Qualifications
1. Degree/ Diploma holders preferably in clinical studies (nursing)
2. University Graduate in a relevant field will be an added advantage
3. Proficient in the use of Microsoft Office suite & packages (Word, Excel, PowerPoint and Vision)
4. Basic understanding of the concepts of insurance
Relevant Experience
Minimum of 5-years relevant experience preferably in care management field