Care Manager

Madison Group Limited is a diversified financial services group in Kenya, offering general insurance, life assurance, and investment management services through its subsidiaries, including Madison General Insurance Kenya Limited.

Madison General Insurance Kenya Limited, a subsidiary of Madison Group, is seeking a Care Manager. This role primarily involves managing care, specifically handling pre-authorizations for outpatient, optical, and dental services. The manager will ensure timely communication with providers, clients, and brokers regarding undertakings, rejections, and other relevant concerns, and will also be responsible for managing the 24-hour emergency helpline. The position requires adherence to policy provisions for approvals and declines, maintaining appropriate turnaround times, and seeking necessary medical clarifications from providers. The role also involves collaborating with the claims team, resolving problems ethically, engaging providers on cost agreements, ensuring data accuracy in the system, and liaising with underwriting and provider relations departments. Additionally, the manager will contribute to strategic initiatives, achieve customer service targets, ensure compliance with regulations, and conduct client presentations on risk management.

1. Ensure undertakings and declines align with policy provisions and are accurately interpreted.
2. Adhere to appropriate turnaround times for issuing approvals.
3. Obtain medical clarifications, including reports and investigation results, from providers as per standard procedures.
4. Communicate all necessary claim decisions to clients and brokers promptly.
5. Collaborate with the claims team by providing information required for claims, especially when new details alter previous undertakings.
6. Interact with clients, brokers, and providers to resolve issues in a legal, ethical, and policy-consistent manner.
7. Engage providers regarding costs, discounts, pre-agreed rates, packages, and fixed/average cost agreements.
8. Ensure accurate information capture in the system with a zero-error rate in benefit adjudication.
9. Liaise with the underwriting department on the scope of cover for various schemes.
10. Coordinate with the provider relations section on matters concerning the provider panel and customer complaints.
11. Manage the 24-hour emergency helpline.
12. Implement departmental strategic initiatives and recommendations from the claims QA committee.
13. Achieve target NPS scores for all customer service indicators.
14. Ensure compliance with internal business processes, IRA Regulations/guidelines, and departmental work ethics.
15. Conduct client presentations and member education on wise utilization and risk management.
16. Support the care management team to meet all deliverables within specified turnaround times.

1. Bachelor’s degree in nursing or clinical medicine.
2. At least 2 years of experience in case management or a related field.
3. Demonstrated knowledge of managing admissions and discharges.
4. Proficiency in health benefits plan management and policy interpretation.
5. Strong customer service orientation and focus.
6. High sense of responsibility and commitment.
7. Ability to work effectively in a team.
8. Excellent communication skills.
9. Ability to multi-task effectively.
10. Strong negotiation and decision-making skills.