Academic and Professional Qualifications

• Bachelor’s Degree/Diploma in Nursing (KRCHN), Health Management or in a related field.
  
• Possession of Health System Management qualifications would be an added advantage.
  
• Kenya Registered Nurse/Kenya Registered Community Health Nurse
  
• Additional training in customer service is an added advantage.
  

Experience

• At least 2 years of experience in a similar role and industry
  

Technical Competencies

• Proficiency in MS Package
  
• Conversant with medical terminology to explain benefits and claims clearly.
  
• Knowledge of insurance industry and concepts
  
• Knowledge of insurance regulatory requirements
  
• Working knowledge of customer and relationship management
  
• Demonstrated experience in customer management and query resolution within care management
  

• Attend to client’s general queries i.e., answering calls from all customers regarding membership eligibility, claim status, benefit information, and claim payments and/or denials
  
• Inform clients through calls by explaining procedures; answering questions; providing needed information.
  
• Ensure medical pre-authorizations/undertakings/ admissions / discharges /declines are issued in compliance with the policy provisions and as per the authority limits.
  
• Ensure that issues escalated, either through emails or calls, are resolved within stipulated timelines to ensure customer satisfaction and loyalty.
  
• Liaise with doctors, brokers and clients via phone or emails for patient admissions.
  
• Advise members on how best to utilise their benefits by recommending cheaper facilities and cheaper options e.g., maternity packages, chronic management facilities
  
• Log claims on the system on a timely basis.
  
• Monitor the turnaround time on email response by logging in the time emails are received on the care team email address
  
• Liaising with our underwriters for scheme membership / benefit / members / dependants missing details in the system and scope of cover
  
• Proper handing over of admissions and discharges above the authorized limit to the care nurse/ care senior officer
  

Complaints Management and Audit Compliance

• Observe guided information to clients and relevant authorized parties are done in compliance with the Data Protection Act
  
• Receive customer complaints or queries and document the same
  
• Follow up on the complaints and ensure they are resolved within set service level agreements.
  
• Communicate feedback to clients
  
• Participate in the process of identifying service gaps and give feedback on necessary corrective measures.
  
• Ensure that all issues are assigned to relevant parties and closed.
  
• Ensure follow-through of the set-out policies and procedures.