Care Manager at Jubilee Insurance

Job Reference Number: HRJIC603 

Role Purpose

We currently have an exciting career opportunity for Care Manager, Jubilee Health Insurance Limited (JHIL). The position holder will report to the Senior Care Manager and will be based at Head Office in Nairobi.

Role Purpose
Care Management, handling all inpatient and specialized test preauthorization, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns. Also, engaging/visiting admitted clients to monitor their stay.

Main Responsibilities

1. Undertaking of admissions (including declines)
2. Data collection for Pre-authorizations and high claimant bills.
3. Ensure appropriate Turn-around Time is adhered to in issuing inpatient and outpatient approvals.
4. Seeking medical clarifications including medical reports, copies of investigation reports, etc.
5. Broker/customer relations by communicating all necessary admission claim decisions on a timely basis.
6. Care Management – Through due diligence, ensuring undertakings are issued in line with the policy provisions. The same should be applied for declines, ensuring that the decisions are accurate and a correct interpretation of the policy.
7. Work with the inpatient claims assessor(s) for inpatient claims and coordinating on any information noted in the inpatient claim submitted especially in cases where further information provided changes the position undertaken previously on the claim.
8. Reviewing medical pre-authorizations for compliance with applicable policy guidelines.
9. 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.
10. Participating in care management meetings
11. Visiting/engaging admitted patients and ensuring quality and cost-effective quality care is given
12. Engaging providers on matters cost, discounts & NHIF
13. Checking and confirming membership validity and benefits (from the scheme benefits file)
14. Handling of coverage enquiries with brokers, providers, members etc.
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 benefit utilization & risk management
20. Managing the 24-hour emergency helpline

Key Competencies

1. Good Clinical acumen
2. Customer Focus
3. Ownership & Commitment
4. Team Spirit
5. Business awareness
6. Communication skills
7. Integrity

Functional Skills

1. Performance reporting and management
2. Health Benefits Plan Management
3. Intelligence and Business Development skills
4. Policy Interpretation
5. Customer Service skills

Additional Desirable skills

1. Good French Speaking and Writing Skills

Qualifications

1. Degree/ Diploma holders, preferably in clinical studies (Nursing/Clinical Medicine)
2. Basic understanding of the concepts of insurance (Certificate of proficiency) is an added advantage.
3. Proficient in the use of Microsoft office suite and packages

Relevant Experience

A minimum of 3 years relevant experience in a busy insurance company and/or hospital