Senior Case Manager – Care Management, Wellness and CDMP at PACIS Insurance

PURPOSE OF THE JOB

• Collaborate with medical clients, intermediaries, and medical service providers to facilitate access to quality, timely, effective, and cost-efficient healthcare services with the aim of achieving business growth, profitability, and customer retention.
• Improve management and outcome of specified medical condition while containing cost for clients with newly diagnosed or long-standing medical conditions.
• Client retention and satisfaction through promotion of self-management of medical condition and involvement in their care.
• To achieve desired health outcomes and enhance quality of care for clients with specified chronic conditions.

KEY RESPONSIBILITIES

Care Management

• Pre-authorize admission, discharges, scheduled and emergency medical cases, issue timely responses as per policy benefits and company guidelines.
• Review patient’s history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.
• Coordinate local and international emergency evacuations, referrals, and transfers
• Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.
• Negotiate doctors’ and hospital bills and charges in view of reducing the cost of care before or during admissions.
• Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi.
• Follow through and resolve escalated customers and provider queries and complains in time and advisethem on outcome and the details of the medical product.

Chronic Disease Management

• Early identification and assessment of members through periodic claims analysis for admittance / enrolment into the chronic disease management program
• In conjunction with the Physician, proactively manage chronically ill members with the objective of improving quality outcomes and containing costs
• Apply case management concepts, principles, and strategies in the development of an individualized case plan that addresses the member’s needs
• Conducts regular discussions and updates with the member’s primary care physicians regarding the status and/or management of a particular member
• Develop new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing their lengths of stay
• In conjunction with the Physician, develops alternative healthcare methods that promote the provision of cost-effective healthcare and the preservation of the member benefits.
• In coordination with provider relations, recruit healthcare providers and negotiate favourable wellness packages for members.
• Prepare a drug formulary that is cost effective and ensures quality outcomes for our clients

Wellness and Medical Advisory

• Coordinate member education, health talks, medical camps and other preventive care programs for members.
• Identify and enroll members on the drug delivery program and in coordination with the healthcare providers ensure seamless delivery of the medication. Assist in scheme performance reviews and give recommendations with the aim of reducing the loss ratios.
• Carry out risk assessment on members’ pre-joining medicals in coordination with the underwriting team and advise on appropriate measures.

Customer Service

•  Weekly, Monthly, and quarterly engagement with members through educative health articles and nuggets, preventive and curative care tips.
• Conduct Post discharge follow-up calls for members to enhance customer service
• Handle and resolve escalated customer service complaints from team members within 24 hours and escalate complex cases to the Manager

KNOWLEDGE AND EXPERIENCE
Academic Qualifications

•  Bachelor’s degree Nursing/ Diploma in Nursing

Professional Qualifications

•  Nursing Council of Kenya
•  AIIK

Experience:

•  Four years’ experience in health insurance

Knowledge

•  Understanding of insurance industry

SKILLS AND COMPETENCIES

•  Excellent communication and Interpersonal Skills.
•  Problem Solving
•  Empathy
•  Decision Making
•  Negotiation Skills
•  Ethical
•  Team Player
•  Keen to detail
•  Planning & Organization Skills
•  Customer Oriented
•  Stakeholder management
•  Dependability