Care Management, handling Outpatient, Optical and Dental preauthorizations, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns and managing the 24-hour emergency line. Directly responsible to achieve the targets of the Outpatient Care Management department.

• Care Management – Through due diligence, ensuring undertakings are issued in line with the policy provisions Likewise, for declines, ensuring that the decisions are accurate and a correct interpretation of the policy
• Ensure appropriate Turnaround Time is adhered to in issuing approvals.
• Seeking medical clarifications including medical reports, copies of investigation reports
• Broker/customer relations by communicating all necessary claim decisions on a timely basis.
• Work with the claims team and coordinating on any information noted in the claims especially inpatient claims submitted in cases where further information provided changes the position undertaken previously on the claim.
• Reviewing medical pre-authorizations for compliance with applicable policy guidelines.
• 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.
• Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost model & other contractual agreements.
• Checking and confirming membership validity and benefits (from the scheme benefits file)
• Handling of coverage enquiries with brokers, providers, members, general public etc.
• 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.
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
• Obtaining additional required information on claims from providers, brokers or clients
• Liaising with underwriting section on scope of cover for various schemes
• Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc
• Client presentations and member education on wise utilization & risk management
• Managing the 24-hour emergency helpline
• Support the care management team to ensure all the deliverables are met within the given turnaround time
• Implementation of strategic initiatives for the department and recommendations by claims QA committee.
• Achieve an NPS scope on all customer service indicators.
• Ensure weekly QA reports are issued on all key indicators.
• Compliance to internal business processes, IRA Regulations/guidelines and adherence to work Ethics for the department
• Staff development, mentorship and Retention.
• Closure of any Audit issues
• Leading the team to achieving the above and the departmental targets.

• Internal: All Staff and intermediaries
• External: All Healthcare Service Providers, Customers and intermediaries

• Health Benefits Plan Management
• Policy Interpretation
• Customer Service
• Team Management
• Cross-functional collaboration
• Excellent communication skills

• BSC Nursing/Clinical Medicine or relevant medical field.
• One-year experience in leading care management in health insurance.
• Experience in working in a medical call centre.

Applications should be addressed to the Group Human Resources Manager, Madison Group Limited, Email: hr_recruitment@madison.co.ke so as to be received by Friday 30 th May, 2025.

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