Care Manager -Medical Insurance -Urgent (For a Medical Insurance Provider Company)

EMPLOYER:      A LEADING MEDICAL INSURANCE PROVIDER OFFERING BOTH LOCAL AND INTERNATIONAL HEALTHCARE SOLUTIONS
REF NO:      SGK-CM-12-2022
INDUSTRY:      INSURANCE
JOB CATEGORY:      SUPERVISORY
TOWN:      NAIROBI
COUNTRY:      KENYA

REQUIREMENTS:      
Diploma or degree in nursing, clinical medicine, medical studies or other related field.

EXPERIENCE:      
At least 1 or 2 years working experience in an insurance company or hospital facility as a care manager.

DUTIES:      The main role of care manager is individual case management of medical cases, both elective and emergencies, to ensure quality care with special focus on exceptional customer service and balancing financial savings. This role ensures that all parties (broker, company, provider, service partner, and company staff) involved are kept up to date on the progress of authorization and case details.

OTHER RESPONSIBILITIES INCLUDES:-
- Check daily with all hospitals for any admissions during the previous night or weekend.
- Receiving lists of hospitalizations from all hospitals along with necessary completed pre-authorization forms, medical reports, estimated length of stay and cost estimate.
- Preauth team member will review, triage and assign cases within the team, will acknowledge receipt the same day.
- Acknowledging urgent /emergency admissions within one hour.
- Checking policy details in navision and completing a preauthorization claims log.
- Sending approval request to aetna international after obtaining all necessary initial documents (completed pre-authorization forms, medical reports, estimated length of stay and cost estimate) with coverage recommendations in timely fashion.
- Follow up on coverage decision (full / partial approval or denial) and guarantee of payment.
- Check if coverage decision is appropriate as per the policy terms & conditions, particularly the full / partial denials.
- Send gop or denial to doctor/member/broker once coverage decision is received, satisfactorily explaining the full / partial denials along with justifiable & timely answers to any additional queries.
- Following up in a timely manner with hospital/doctor for additional medical and cost updates to justify further approval if a limited approval was given.
- Review and coordinate with aetna regarding any inaccurate full / partial denials, obtain and share additional medical information from the treating doctor where necessary and ensure that all cases are 100% accurate as per the policy terms.
- Plan and execute full range of case management actions for all complex, high cost and contested cases for end-to-end case and cost management in liaison with aetna international, provider and broker.
- Daily coordinate with the treating doctor’s office regarding all inpatient cases, with particular focus on complex and high cost cases for end-to-end case and cost management in liaison with aetna international for sharing treatment progress and obtaining necessary approvals, communicating any partial / full denials as appropriate immediately with the treating doctor and the member / family.
- Full adherence to terms of all insurance products, compliance requirements and policies related to privacy of medical information / secured handling of member’s medical information – for instance, getting a romif signed from a member as per the country’s requirement where member is receiving treatment.
- Handle all pre-authorization processes electronically in navision and eliminate the use of any manual methods unless agreed to improve process efficiency and for accurate management reporting.
- Initiate, promote and participate in process improvement activities, systems and explicit measures that ensure timely and accurate execution of pre-authorization dept objectives.
- Generate, organize, and analyze preauthorization data every month, quarter, and annually as assigned by the line manager; help compiling reports mentioning key findings and trends related to tats, accuracy, medical utilization, medical cost savings and excellence in customer service.

SALARY:      KSHS. 60,000 - 120,000 PLUS COMPANY BENEFITS