Case Management Officer

Overview

Under the supervision of the Manager Clinicals, the Case Management Officer is entrusted with overseeing the policy lifecycle through pre-authorization and diligent case management. The role aims to uphold quality healthcare services while ensuring cost-effectiveness in medical care delivery.

Key Duties

• Establish suitable parameters for each patient admission, including claim reserves, initial authorized expenses, and duration of care.
• Communicate effectively with clients and healthcare providers to guarantee that care aligns with the established policy guidelines.
• Assess medical reports and claims meticulously for adherence to organizational guidelines.
• Collaborate with underwriting teams to clarify coverage scope for various insurance schemes.
• Ensure medical scheme members receive continuous support with cooperation from a 24-hour call center.
• Actively minimize poly-pharmacy by carefully reviewing prescriptions and recommending improved treatment alternatives.
• Promote the substitution of generic medications where suitable, aiming to lower pharmaceutical costs.
• Operate within the boundaries outlined in the approved Delegated Authority Matrix.
• Generate regular reports for management regarding medical claims and their statuses.
• Ensure timeliness in claims processing as per stipulated timeframes.
• Perform additional duties as assigned periodically.

Qualifications and Experience

• Holds a Diploma or Degree in Nursing, Clinical Medicine, or Pharmacy.
• Possesses a solid understanding of insurance principles.
• Professional certifications such as FLMI, ACII, or IIK are advantageous but not mandatory.
• A minimum of 3 to 4 years of experience in case management is required.

Additional Information

• Location: Nairobi, Kenya.
• Employment Type: Full-time permanent position.
• Work Schedule: Day shifts.
• Organization: Britam.
• Job posting date: August 12, 2026; ongoing vacancy.