Assistant Manager Case Management - Medical Insurance Business (First Assurance Kenya) at Absa Bank Limited

Job Summary

To lead and oversee care management operations, including inpatient preauthorizations and utilization management, ensuring the delivery of high-quality, timely, and cost-effective healthcare. The role involves conducting clinical case reviews, coordinating communication with providers, clients, and intermediaries, ensuring adherence to best practices, and guiding care management decisions. Additionally, the role provides supervision and mentorship to care management staff to support quality outcomes, operational efficiency, and sustainable business growth.

Job Description

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.
Compile periodic reports detailing the observed trends and recommended risk mitigation measures


Accountability: Operations Management


Oversee the day-to-day case management, ensuring efficient and effective service delivery of services to clients.
Oversee review of patient's history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.
Ensure appropriate turnaround time is adhered to in issuing approvals.
Maintain detailed and accurate records of assessments, care plans, and interactions with policyholders and healthcare providers.
Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.
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.
Oversee negotiation of doctors' and hospital bills and charges in view of reducing the cost of care before or during admissions.
Coordinate local and international emergency evacuations, referrals, and transfers.
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.
Coordinating of the contact center and ensure clients have access to the 24hour hotlines.
Oversee continuous update of the intermediaries and/ or scheme administrators about client's progress and provide requested updates.
Register, follow through and resolve the customers and provider queries and complains in time and advise them on outcome and the details of the medical product.


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 plans for the area and re-allocate resources where required.
Entrenching performance-based appraisal of department staff in line with their set KPI


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.


Education and Qualifications Required


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