Case Management Officer

The Aga Khan Hospital, Kisumu is a healthcare institution founded in 1952, providing comprehensive medical services in Kisumu, Kenya.

The Case Management Officer reports to the Assistant Claims Manager and is responsible for proactively managing clinical care plans, utilization, and treatment protocols during active patient care. This includes ensuring all medical claims are accurately audited, ICD-10 coded, and verified before dispatch. The officer serves as a vital intermediary between clinical care and hospital financial operations, collaborating with corporate and insurance clients, attending physicians, and internal billing teams to address clinical inquiries, clear discharge documentation, and implement controls to reduce claim rejections and revenue loss, in adherence to the institution's finance policy.

1. Monitor patient care in real-time, tracking length of stay, clinical necessity, and treatment plans, while securing pre-authorizations and limit extensions on scheme portals.
2. Inform clinical teams and patients about policy exclusions, limits, and co-pays early to manage expectations and prevent billing disputes.
3. Act as the primary clinical liaison between doctors, hospital staff, and corporate/insurance case managers, ensuring smooth, fully coded billing clearance at discharge.
4. Audit treatment patterns to prevent over-utilization of drugs or duplicate tests and ensure adherence to standard clinical protocols.
5. Verify claims before processing them for dispatch to corporate clients.
6. Confirm that diagnoses match issued drugs and investigations.
7. Identify and highlight corporate exclusions regarding prescribed drugs and implement strategies to reduce rejections before claims are dispatched.
8. Sign on behalf of doctors when signatures are missing.
9. Fill out claim forms for invoices that lack them.
10. Collaborate with the dispatch section to verify claims prior to dispatch.
11. Reconcile rejections related to clinical issues and other returned invoices.
12. Monitor invoice returns and take appropriate action on clinical issues and queries within one week.
13. Lead efforts to address reasons for returns to prevent future recurrence.
14. Prepare rejection analyses on clinical issues and monthly reports to guide institutional control status.
15. Work with the Debtors team to review all clinical issues within reconciliation for sign-off with corporate clients.
16. Facilitate the closure of all rejected invoices due to medical issues.
17. Develop proficiency in the ICD-10 coding system and coding tools.
18. Familiarize oneself with insurance scheme platforms such as Smart, Slade, LCT, M-TIBA, and others.
19. Develop proficiency in CareWeb ICD Voucher Wise ICD entry and coding procedures.
20. Ensure 100% of insurance claim forms requiring ICD-10 coding in CareWeb ICD Voucher Wise are collated, accurately coded, and completed within the stipulated timeframe.
21. Ensure 100% of insurance claim forms requiring ICD-10 coding on insurance scheme platforms are collated, accurately coded, and completed within the stipulated timeframe.
22. Aggregate, review, and follow up on claims with missing or incomplete diagnoses daily and weekly to facilitate timely and accurate coding and submission.
23. Participate in all team efforts as departmental needs arise.
24. Perform other duties as assigned by the Manager.

1. Hold a Diploma in Clinical Medicine or an equivalent qualification from a recognized institution.
2. Possess a current practicing certificate.
3. Be registered as a member of the relevant professional body.
4. Have a minimum of 3 years of relevant experience in a busy hospital or insurance setting.
5. Demonstrate a results-driven, ethical, and adaptable professional approach with a strong focus on service and stakeholders.
6. Exhibit strong integrity and sensitivity in managing confidential information.