The Assistant Case Manager at PACIS Insurance Company Limited is responsible for collaborating with medical clients, intermediaries, and medical service providers to facilitate access to quality, timely, effective, and cost-efficient healthcare services. The role aims to achieve business growth, profitability, and customer retention by managing the intersection of clinical care and insurance policy administration.
Principal Accountabilities
Claims Processing
Membership Verification: Confirming membership, validity, and benefits before processing claims.
Bill Vetting: Capturing and vetting medical bills within the client’s benefit structure and as per negotiated customary, reasonable rates.
Reserving: Correctly reserving inpatient bills on discharge and approved outpatient cases.
Remittances: Preparing and sending the correct reimbursement remittances to clients.
Dispute Resolution: Communicating any claim dispute or rejection to clients and intermediaries.
Case Management and Customer Service
Emergency Response: Receiving and responding to medical emergency lines and ensuring 24-hour coverage.
Authorizations: Issuance of both inpatient and outpatient approvals for admissible requests for insured members.
Stakeholder Communication: Notifying stakeholders on management of cases, discharges, admissions, and financial liability.
Social Health Authority Coordination: Coordinating with clients and medical providers to leverage SHA (formerly NHIF) rebates and packages.
Cost Containment: Negotiating hospital and doctors’ charges with the aim of optimal cost containment before or during admissions.
Provider Support: Weekly distribution of active members list to preferred panel of providers.
Patient Visitation: Visiting patients admitted within Nairobi and following up on those admitted outside Nairobi.
Inquiry Management: Resolving all customer queries immediately and promptly escalating complex cases.
Reporting: Sending weekly and monthly reports on admissions, exceptional claims, long stay, savings, and claims production.
Qualifications and Experience
Minimum Academic Qualification
Bachelor's degree in Nursing, or a Diploma in Nursing / Clinical Medicine.
Professional Qualifications
Registration with the Nursing Council of Kenya.
AIIK or Certificate of Proficiency (COP) in Insurance.
Experience
One year’s experience in health insurance operations.
How to Apply
Interested and qualified candidates should apply online by visiting the PACIS Insurance website at www.pacisinsurance.com or directly via the application portal at https://www.myjobmag.co.ke/apply-now/1210628. Applications must be submitted no later than May 3, 2026.
