The Case Management Officer is responsible for controlling and managing insurance policies through clinical case management. The primary objective is to ensure that medical scheme members receive quality and cost-effective care while managing the end-to-end process of Electronic Medical Claims (EMC), from authorization to payment.
Key Responsibilities
Admission Management: Set the appropriate parameters for each hospital admission, including claim reserves, initial authorized costs, and duration of stay.
Provider & Client Interaction: Interact with clients and service providers to ensure care is delivered within policy guidelines.
Clinical Review: Audit and review medical reports and claims for compliance with set clinical guidelines.
Underwriting Liaison: Collaborate with underwriters regarding the scope of cover for various schemes.
24-Hour Support: Ensure medical scheme members are attended to round the clock with support from the 24-hour call center.
Pharmacy Management: Discourage poly-pharmacy by challenging prescriptions and suggesting better alternatives; encourage generic substitution to reduce pharmaceutical expenditure.
Claim Auditing: Verify and audit outpatient and inpatient claims to ensure compliance and mitigate financial risk.
Customer Advisory: Advise claimants regarding insurance coverage and respond to inquiries concerning the claims process and service providers.
Record Keeping: Maintain accurate claims transactions, prepare claims registers for meetings, and update relevant reports.
Administrative Duties: Track and follow up on the receipt of necessary documents and perform other duties as assigned.
Qualifications and Experience
Professional Certification: Professional Nursing qualification (KRCHN) and must be licensed by the Nursing Council of Kenya.
Education: BA/BSc/HND degree in a relevant field.
Experience: 2–4 years of experience specifically in case management and claims processing.
Regulatory Knowledge: Sound knowledge of insurance regulatory requirements and insurance products.
How to Apply
Qualified candidates are invited to submit their applications through the Britam career portal at https://www.myjobmag.co.ke/apply-now/1215291 before the application deadline of May 5, 2026.
How to Apply
Interested and qualified candidates should apply online via the Britam recruitment portal at https://www.myjobmag.co.ke/apply-now/1215291. Ensure you meet the KRCHN licensing requirement before applying.
