The Assistant Case Manager collaborates 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.
Principal Accountabilities
Claims Processing
Member Verification: Confirmation of membership, validity, and benefits before processing claims.
Bill Vetting: Capture and vet medical bills within the client’s benefit structure and as per negotiated customary, reasonable rates.
Reserving: Correctly reserve inpatient bills on discharge and approved outpatient cases.
Remittances: Preparing and sending the correct reimbursement remittances to clients.
Dispute Communication: Communicating any claim dispute or rejection to the clients and intermediaries.
Case Management and Customer Service
Emergency Support: Receive and respond to medical emergency lines and ensure 24-hour coverage.
Approvals: Issuance of both inpatient and outpatient approvals for admissible requests for insured members.
Stakeholder Notification: Communication and notification to stakeholders on management of cases, discharges, admissions, and financial liability.
Rebate Coordination: Coordinate with clients and medical providers to leverage on SHA rebates and packages.
Cost Containment: Negotiation of hospital and doctors’ charges with the aim of optimal cost containment before or during admissions.
Provider Coordination: Weekly running and sending out active members list to preferred panel of providers.
Patient Visitation: Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi.
Inquiry Resolution: Resolve all customer queries immediately and promptly escalate complex cases.
Reporting: Send weekly and monthly reports on admissions, exceptional claims, long stay, savings, and claims production among others.
Qualifications and Experience
Minimum Academic Qualification
Bachelor's degree in Nursing or a Diploma in Nursing/Clinical Medicine.
Professional Qualifications
Valid registration with the Nursing Council of Kenya.
AIIK or Certificate of Proficiency in Insurance.
Experience
At least one year’s experience in health insurance.
