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Case Management Nurse

Closing: Jun 12, 2024

This position has expired

Published: Jun 5, 2024 (20 days ago)

Job Requirements

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Job Summary

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To control and manage medical benefit utilization through preauthorization and case management activities and ensure quality, appropriate cost-effective care and good customer service

SKILLS AND COMPETENCIES

  • Excellent communication and negotiation skills.
  • Excellent public relations and interpersonal relationship skills.
  • Extensive networking with SP and other medical insurers.
  • Excellent analytical and monitoring skills
  • Good IT skills in database management and office systems.
  • Good decision making in benefit utilization management.
  • High levels of integrity and honesty

QUALIFICATIONS, KNOWLEDGE & EXPERIENCE

  • Diploma or Degree in Nursing                     
  • Diploma in Insurance/ COP
  • Degree in Health systems Management/ Business management 
  • 3 years’ experience in clinical setting +2 years in insurance set up


Responsibilities
To control and manage medical benefit utilization through preauthorization and case management activities and ensure quality, appropriate cost-effective care and good customer service

SKILLS AND COMPETENCIES

  • Excellent communication and negotiation skills.
  • Excellent public relations and interpersonal relationship skills.
  • Extensive networking with SP and other medical insurers.
  • Excellent analytical and monitoring skills
  • Good IT skills in database management and office systems.
  • Good decision making in benefit utilization management.
  • High levels of integrity and honesty

QUALIFICATIONS, KNOWLEDGE & EXPERIENCE

  • Diploma or Degree in Nursing                     
  • Diploma in Insurance/ COP
  • Degree in Health systems Management/ Business management 
  • 3 years’ experience in clinical setting +2 years in insurance set up


  • Pre-authorize scheduled and non-scheduled admissions within the set guidelines.
  • Negotiate/discuss professional fees as appropriate for each admission.
  • Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
  • Visit all admitted clients within Nairobi region and its environs
  • Liaise with Doctors on the day-to-day management of patients and obtain medical reports/ expected length of stay where indicated.
  • Ensure smooth discharge process and co-ordinate any necessary post-hospitalization/ step down facility care.
  • Revise reserves after discharge of member.
  • Collect feedback from admitted clients on quality and scope of service by the service provider.
  • Assist in carrying out verification and medical audit of claims/invoices before settlement.
  • Develop and maintain monthly database on admissions, large claims and extended length of stay.
  • Respond to queries from clients, intermediaries and service providers.
  • Liaise with other medical underwriter for purposes of market surveys and development of new controls, standards and products.
  • Any other duty assigned by management.


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