Care Manager (Ruiru) at Plainsview Hospital

Role of Purpose
To manage medical cases, both elective and emergencies, ensure quality care with special focus on exceptional customer service and balance financial saving in the Hospital.

Duties and Responsibilities

• Check policy details and complete a preauthorization claims log.
• Sending approval request to insurance companies after obtaining all necessary initial documents (completed pre-authorization forms, medical reports, estimated length of stay and cost estimate) with coverage recommendations in timely fashion.
• Plan and execute full range of case management actions for all complex, high cost and contested cases for end-to-end case and cost management in liaison with Insurance companies.
• Check if coverage decision is appropriate as per the policy terms & conditions, particularly the full and partial denials.
• Send coverage denials to doctors, members and Insurance companies once coverage decision is received, satisfactorily explaining the full or partial denials along with justifiable & timely answers to any additional queries.
• Following up in a timely manner with doctors for additional medical and cost updates to justify further approval if a limited approval was given.
• Review and coordinate with Insurance companies regarding any inaccurate full or partial denials, obtain and share additional medical information from the treating doctor where necessary and ensure that all cases are 100% accurate as per the policy terms.
• Ensure full adherence to terms of all insurance products, compliance requirements and policies related to privacy of medical information.
• Identify conflicts in patient care and make judgment calls as to the best path forward
• Oversee the implementation of a patient’s medical plan
• Deal with Insurance companies on matters concerning overdue debt follow ups, updated statements,

Qualifications

• Bachelor Degree in nursing, clinical medicine, medical studies or other related medical field
• Minimum three (3) years’ working experience in an insurance company or hospital facility as a care manager.
• Complied with the requirements of Chapter Six (6) of the Constitution of Kenya.
• Previous experience as a care manager is an added advantage