Senior Case/Care Manager - Medical Business (First Assurance Kenya)

Education and Qualifications Required (Essential):

• Bachelor’s degree in nursing/clinical medicine or a diploma in nursing/clinical medicine with a diploma in insurance.
  
• A diploma in insurance will be an added advantage.
  
• Relevant professional qualification.
  
• Must be a member of a professional body in good standing.
  

Accountability: Strategic:

• Develop and implement the overall strategic plan for the Care/ Case Management Sections of the Medical business, aligned with the company’s overall business objectives.
  
• Ensure Formulation and implementation of policies and strategies for effective and efficient case management.
  
• Execute robust case management strategies aligned with the organization's mission and objectives.
  
• Identify opportunities for innovative interventions, process enhancements, and cost-effective healthcare solutions.
  
• Stay updated with industry trends, healthcare practices, and regulatory changes to inform strategic decision-making.
  
• Engaging providers on matters cost, discounts, pre agreed rates, packages/fixed cost model.
  
• Monitor, analyse, and report on case management outcomes to drive continuous improvement.
  

Accountability: Operations Management:

• Oversee the day-to-day case management, ensuring efficient and effective service delivery of services to clients.
  
• Visiting/engaging admitted patients and ensuring they receive quality and cost-effective quality care.
  
• Ensure appropriate turnaround time is adhered to in issuing approvals.
  
• Reviewing medical pre authorizations for compliance with applicable policy guidelines.
  
• Maintain detailed and accurate records of assessments, care plans, and interactions with policyholders and healthcare providers.
  
• Monitor the quality of healthcare services provided to policyholders.
  
• Identify opportunities for improvement and work with healthcare providers to enhance care quality.
  
• Work to manage healthcare costs by ensuring that care is appropriate, cost-effective, and aligned with policy coverage.
  
• Evaluate active insurance cases to understand policy coverage, claim status, and the specific needs and concerns of policyholders.
  
• Develop and maintain strong relationships with healthcare service providers, negotiating favourable rates and service agreements.
  
• Liaising with provider relations section on matters pertaining to provider panel, customer complaints.
  
• Support the care management team to ensure all the deliverables are met within the given turnaround time
  

Accountability: People Management:

• Lead, mentor and develop a high performing team of medical insurance professionals.
  
• Foster a positive and collaborative work environment that encourages innovation and teamwork
  
• Together with the Human Capital Team, determine the people management strategy for the area with a focus on talent management, development, resourcing and retention. Communicate the strategy to managers in the area.
  
• Recruit, hire and onboard talented individuals to support the growth of the medical insurance business
  
• Review workforce and recruitment plan for the area and re-allocate resources where required.
  

Accountability: Risk Management:

• Identify and mitigate potential risks associated with the medical insurance business, including operational, financial, and reputational risks.
  
• Ensure compliance with all relevant regulatory requirements.
  
• Ensure strict compliance with healthcare regulations, insurance guidelines, and ethical standards within the Care/Case Management function.
  
• Collaborate with legal and compliance teams to address complex regulatory and legal issues related to case management.
  
• Ensure all case management activities adhere to healthcare regulations, insurance policies, and ethical standards.
  
• Drive a culture of proactive compliance in the function.
  

• Any other duties that fall under the responsibility of the Case/Care Manager at First Assurance Company.