Job Summary:
The primary purpose of the Care officer role is to deliver clinical oversight and case management for insured members requiring hospitalization. The role is responsible for ensuring that members receive medically appropriate, high-quality, and cost-effective care, while also safeguarding the financial sustainability of the medical scheme. This includes evaluating pre-authorizations, monitoring inpatient admissions and coordinating with healthcare providers. The position requires strong clinical acumen, a deep understanding of medical insurance operations, benefit structures, and regulatory requirements.
Duties and Responsibilities:
- Ensure proper care and treatment of patient within acceptable protocols to mitigate overuse of cover by member / provider
- Vet and review claim documents with the goal of determining the validity as reported in the claim form to determine eligibility including validity and benefits as per policy guidelines
- Prepare daily reports of admissions in the various service providers
- Attend to all our customers and ensure complicated and disputed cases at the call centre are escalated and resolved within the agreed timelines.
- Undertake timely claims processing within the timelines of provider payment schedules
- Obtain additional required information on claims from providers, brokers or clients by going through pre-authorization forms and scrutinize forms for correct diagnosis
- Undertaking patient visits to ensure quality service, correct treatment and eligibility where required explain the medical terms of cover or where queried
- Inform the provider manager / provider management team on any anomalies of provider service / quality concerns
- Review and resolution of complex cases and provide appropriate clinical expertise on diagnosis / treatment within policy coverage including where clients require medical guidance and escalate where necessary
- Interact with clients, brokers and clinicians as needed, informing them as necessary admission claim decisions on a timely basis, to resolve problems within the guidelines of the policy and escalate where necessary
- Liaise with underwriting section on clarity of scope and omission
- Provide support in the preparation of client presentations and member education on wise usage of cover
Academic and Professional Qualifications
- Bachelor’s degree/Diploma in nursing or clinical medicine, or a related field.
- Professional Nursing qualification KRCHN licensed by Nursing council of Kenya.
- Relevant certifications in case management, healthcare management, or clinical specialties.
Experience
- At least 3 years’ case management experience in a medical insurance environment, with demonstrated expertise in inpatient care coordination, insurance benefit administration, policy interpretation, and pre-authorization processes.
- Demonstrated knowledge of managing admissions and discharges
- Experience in provider engagement will be an added advantage.
Technical Competencies
- Experience in managing stakeholders in the health insurance services ecosystem
- Clinical knowledge and ability to interpret medical reports and treatment plans
- Understanding of health insurance policies, benefits, and scheme structures
- Strong case management and utilization review skills
- Analytical thinking and sound decision-making based on clinical and policy guidelines
- Attention to detail and accuracy in documentation and benefit adjudication
- Excellent communication and interpersonal skills for engaging clients, providers, and internal teams
- Customer service orientation with empathy and professionalism
- Negotiation and relationship management skills with service providers and stakeholders
- Knowledge of compliance requirements, medical ethics, and healthcare regulations
- Ability to identify and mitigate fraud, waste, and abuse in claims
- Knowledge of emerging trends and procedures in health insurance services management
- Working knowledge of diagnostic procedures within the Kenya healthcare system
Behavioural Competencies
- Strong customer service
- Strong analytical and problem-solving skills
- Results driven and action oriented
- Collaborative team player
- Strong attention to detail
- Agile mindset with demonstrated ability to manage tasks with competing deadlines
- High degree of emotional intelligence, integrity, trust and dependability
- Ability to work independently as well as part of a team
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Job Summary: The job holder will develop, manage, and sustain relationships with healthcare provider networks to secure high-quality and cost-effective health care services. The main goal is to shape a comprehensive and integrated health care system by fostering a seamless and efficient service network.
Duties and Responsibilities:
- Strategic Partnerships – continuous engagement with providers to ensure provision of high-quality, cost-effective care.
- Provider network management – maintain an updated provider panel, monitor adequacy of providers in all key regions and conduct provider audits. Update provider panel and Contacts to ensure the list is current and up to date.
- Provider relationship management – Develop and maintain strong provider relationships to enhance provider and customer experience and to ensure that providers adhere to the contract terms. Organize service meetings, training on GA processes, obtain provider feedback and share relevant reports on providers.
- Provider contracting –assist in contracting of providers and managing the provider contract lifecycle. While also ensuring all current and upcoming providers have signed contracts and have submitted all relevant documentation, carrying out system updates and filing of all relevant provider KYC documents and maintaining reports for the same.
- Customer service support – Support the business development and underwriting team through attending client service meetings to ensure delivery of superior customer experience.
- Compliance- Participate in collection and system updates of provider KYC and licenses to ensure compliance to any regulatory or health sector changes e.g., changes in the health legislation affecting the business and provide compliance reports promptly and as required.
- Cost containment- Negotiate costs, analyze provider costs, claims, and provide prompt reports and data to inform decision making in scheme cost controls.
- Assist in carrying out country-wide provider audits to ensure that quality, cost effective medical services can be guaranteed for clients.
- Provide guidance to, claims team, and contact centre agents on provider issues.
Academic and Professional Qualifications
- Diploma/bachelor’s in nursing or clinical medicine is preferred.
- Any insurance certification will be an added advantage
Experience
- At least 5 years of experience in clinical management or similar role
- Prior relevant experience in health insurance is preferred.
- Extensive knowledge of public and private healthcare providers in Kenya
Technical Competencies
- Proficiency in MS Package
- Experience in managing health insurance medical scheme services
- Knowledge of insurance industry and concepts and regulatory requirements
- Demonstrated experience in provider onboarding requirements in health insurance services management
- Working knowledge of diagnostic procedures within the Kenya healthcare system
- Experience in claims management within provision of medical scheme/ health insurance
- Knowledge of emerging trends and procedures in health insurance services management
- Experience in managing stakeholders in the health insurance services ecosystem
- Extensive networking with SP and other medical insurers.
- Excellent analytical and monitoring skills
- Good decision-making skills.
Behavioural Competencies
- Strong strategic focus and vision driven
- Strong problem solving, conflict management and decision-making capability
- Ability to build strategic relationships and network.
- Demonstrated team spirit and experience in team management through effective delegation and collaboration.
- High emotional intelligence and diplomatic sensitivity
- Ability to effectively manage resources.
- Ability to coach, mentor and develop talent.
- Strong interpersonal and communication skills.
- Strong client focus.
- High level of trust, integrity and dependability
- Innovative and ability to challenge the status quo.
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Job Summary: This position is responsible for achieving business growth within GA Insurance Limited through proper selection of business, enforcement of adequate pricing, monitoring of loss ratios, coordination of renewals, efficient service provision and generation of new business through building of strong client and intermediary relationships.
Duties and Responsibilities:
.Portfolio Profitability & Sustainability
- Develop strategies to maintain a healthy medical portfolio through risk selection, pricing, and benefit design.
- Ensure profitability by monitoring loss ratios and claims patterns to predict future risks and make proactive adjustments.
- Recommend strategic initiatives such as repricing, panel restructuring, and introduction of managed care controls.
Risk Management & Governance
- Establish and continuously refine underwriting policies, guidelines, and frameworks to manage the risk exposures.
- Ensure underwriting decisions align with corporate risk appetite and regulatory requirements.
- Drive quality assurance and audit readiness across underwriting processes.
- Manage leakages to ensure monitoring, collection and non-recurrence i.e. excesses, endorsements, membership invoicing etc.
Product Strategy & Market Positioning
- Provide strategic guidance on pricing models, benefit limits, and product differentiation.
- Support product development and enhancement through insights from claims analytics, market trends, and competitor benchmarking.
Business Growth & Retention strategy
- Support the business development teams to evaluate large or complex corporate accounts by offering underwriting insights to support negotiations and strategic pitches.
- Balance competitiveness with profitability to support sustainable business expansion.
- Implement a comprehensive client retention strategy for the corporate and retail segment, focusing on key drivers of renewal and customer loyalty.
- Create differentiated renewal approaches based on client profiles, focusing on personalized service for all accounts and maintaining profitability across all segments.
Data-Driven Decision Making
- Use claims data, provider utilization patterns, and market intelligence to guide strategic decisions.
- Initiate and Implement forecasting tools and dashboards to track portfolio performance and identify emerging risks.
- Promote digitization and automation in underwriting workflow for better efficiency and accuracy.
Stakeholder Engagement & Relationship Management
- Collaborate cross-functionally with all relevant stakeholders.
- Manage escalations and strategic client relationships, ensuring transparency in underwriting decisions.
- Represent underwriting in executive meetings, board presentations, and regulatory forums.
Leadership & Talent Development
- Set and monitor underwriting KPIs and ensure operational targets are achieved.
- Drive capacity building by mentoring underwriters and ensuring continuous professional development and performance management.
- Foster a high-performance culture focused on accuracy, turnaround time, and customer satisfaction.
- Lead change management and adoption of new systems, technologies, and processes.
Academic and Professional Qualifications
- Bachelor’s degree in business administration, Finance or a related field.
- Professional qualification in Diploma in Insurance (AIIK) or Advanced Diploma in Insurance (ACII) or an equivalent professional qualification
Experience
- At least 6 years of experience, 2 years of which should be in management or similar role and industry
Technical Competencies
- Proficiency in MS Package
- Experience in managing health insurance services
- Knowledge of insurance industry and concepts
- Knowledge of insurance regulatory requirements
- Knowledge of risk and audit compliance requirements in health insurance services management
- Knowledge of emerging trends and procedures in health insurance services management
- Experience in managing stakeholders in the health insurance services ecosystem
Behavioural Competencies
- Strong strategic focus and is vision driven
- Strong achievement focus
- High level of analytical and flexible thinking skills
- Strong problem solving, conflict management and decision-making capability
- Ability to build strategic relationships and network.
- Demonstrated team spirit and experience in team management through effective delegation and collaboration.
- High emotional intelligence and diplomatic sensitivity
- Ability to effectively manage resources.
- Ability to coach, mentor and develop talent.
- Strong interpersonal and communication skills.
- Strong client focus.
- Strong attention to detail
- High level of trust, integrity and dependability.
- Innovative and ability to challenge the status quo.
If you meet the above requirements and wish to be part of our vibrant team in Provider support management team, Health Department please send your application letter and updated CV to the email address careers@gakenya.com by 11th February 2026.Interview will be on rolling basis. Indicate the position you are applying for on the email subject line. Only shortlisted candidates will be contacted.
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