Case Management Nurse at Old Mutual Kenya

Introduction

To control and manage benefits utilization through pre-authorization and case management, ensuring quality, appropriate and cost effective care for our members while safeguarding company interest .

Minimum Requirements

KNOWLEDGE & EXPERIENCE

• Qualified practicing nurse-KRN or equivalent
• 2 Years  in clinical setting

SKILLS & COMPETENCIES

• Excellent analytical skills
• Good communication and negotiation skills
• Excellent interpersonal relations skills
• Good networking with Service providers and other medical insures

Job Specification.

PRINCIPAL ACCOUNTABILITIES

• Pre-authorize scheduled and non-scheduled admissions within set guidelines and negotiate professional fees for each admission and on case by case for in-patient in consultation with Care Management Officer
• Ensure that set parameters for admissions are adhered to
• Implement a chronic condition management program for all our clients with chronic conditions
•  Visit all in-patients within Nairobi and its environs while liaising with the admitting doctors to ensure timely medical reports and smooth discharge and eventual preparation of case report of each admission on discharge and arranges post-hospitalization care.
• Develop and maintain a database on admissions, clinical statistics/profiles 
• Liaise with other medical schemes for purposes of  evaluating medical risk
•  Participate in product presentation and health talks activities on a need basis
• Assist in management of the Preferred Service providers
• Answer incoming telephone calls into the Call Center in a professional manner at all times with an efficiency of above 95%.
• Managing requests for services from providers, intermediaries and clients, providing information on the UAP provider network, available benefits per scheme policy and services and other routine information.  Provides health information to customers via UAP approved resources
•  Completes accurate and timely documentation on CRM of all services provided to callers and escalation of any issues which require further consultation.
• In conjunction with Smart applications resolve card issues raised at the point of service.
• Normal information center duties. E.g. carrying out customer surveys, social media and email management

KEY RESULT AREAS & PERFORMANCE INDICATORS

• Case  Management of all admissions as per  set guidelines
• Cost reductions as per the set targets.
• Pre-Authorization of all admissions within 6 hrs
• All professional fees charges to be within pre-negotiated or set fess guidelines
• Minimized identifiable cases of fraud
• Processing of retail and cooperate outpatient claims
• Provide monthly admission report for retail and weekly for Corporate clients