Care Navigator at Jubilee Insurance

• We currently have an exciting career opportunity for a Care Navigator within Jubilee Health Insurance Limited. The position holder will report to the Assistant Manager, Care Navigation and will be based at our Head Office in Nairobi.

Role Purpose

• The primary purpose of the Care Navigator is to Navigate assigned members and schemes, providing professional guidance on policy matters where requested, ensuring quality and cost-effective service provision and communicating with providers, clients and brokers on a timely basis for any rejections or relevant concerns.

Key Responsibilities
Strategy

• Identify areas for improvement and propose strategies to enhance the program's effectiveness.
• Stay informed about healthcare regulations and policies that may affect clients' access to care.
• Provide input into the development of insurance policies that align with the company's care navigation goals.
• Analyse data related to healthcare utilization, costs, and outcomes to identify trends and opportunities for improvement.
• Use data insights to inform strategic decisions and drive program enhancements.

Operational

• Monitoring health seeking behaviours of assigned members/schemes and implementing appropriate measures to realize population health.
• Enrolment of scheme members into appropriate Wellness Programs
• Monitoring utilization of assigned members/schemes and implementing appropriate control measures
• Organizing and conducting health & member education sessions for assigned schemes.
• Obtaining daily reports of admissions for assigned members/schemes at the various service providers and organizing and/or visiting admitted members.
• Advising clients as necessary on their conditions and navigating members to appropriate service providers for required level of care.
• Ensuring that medical reports shared by the hospital are in line with actual management of the patient and ensuring proper care and treatment of patient within acceptable protocols.
• 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.
• 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.

Corporate Governance

• Uphold high ethical standards in all interactions with clients, healthcare providers, and colleagues.
• Stay informed about healthcare laws and regulations, including those related to insurance and privacy.
• Ensure that all care navigation activities are compliant with these regulations.
• Maintain accurate and complete records of all client interactions and care plans.
• Be transparent with clients about the services offered, potential limitations, and any fees or charges associated with care navigation services.
• Safeguard the confidentiality of client information and adhere to strict privacy policies.
• Classified as Public
• Seek proper authorization before disclosing any client information.

Identify potential risks associated with care navigation activities and work with relevant departments to mitigate those risks Laws, Regulations, Company Policies: Stay informed about and strictly adhering to all external laws, including:

• Anti-Money Laundering (AML) and Counter Financing of Terrorism (CFT) laws, Data Protection laws, and any other relevant regulations applicable in the insurance industry; Understand, implement, and enforce internal company policies, processes and procedures;
• Ensure that operational compliance programs are in place within your department. Implement processes and controls that promote compliance with external laws, regulations, and internal policies; Foster a robust ethical culture within the organization, demonstrating and promoting ethical behaviour, integrity, and compliance with laws and regulations. Encourage open communication and reporting of any potential compliance concerns or violations.

Key Skills and Competencies

• Healthcare Knowledge; A strong understanding of the healthcare system, including insurance plans, medical terminology, and healthcare policies and regulations.
• Communication Skills: Excellent verbal and written communication skills to effectively interact with clients, healthcare providers, and colleagues.
• Empathy and Compassion; The ability to empathize with clients' health concerns and provide compassionate support during difficult times.
• Active Listening: The skill to actively listen to clients, understand their needs, and address their concerns effectively.
• Problem-Solving Skills: Strong problem-solving abilities to help clients overcome barriers to care and find solutions to complex healthcare challenges.
• Organization and Time Management; Efficiently manage caseloads, appointments, and care coordination tasks while maintaining attention to detail.
• Flexibility and Adaptability; Adapt to changing healthcare environments, policies, and client needs.
• Quality Improvement; A commitment to continuous quality improvement and a willingness to participate in initiatives aimed at enhancing care navigation services.

Academic Qualifications

• Degree/ Diploma holders in clinical studies.
• Nursing qualifications is an added advantage.
• At least 2 years’ experience in a clinical setting
• Basic understanding of the concepts of insurance

Relevant Experience

• At least 3-year relevant experience with understanding of medical insurance processes