Pacis Insuarance Ltd hiring Senior Case Manager – Care Management, Wellness and CDMP in Nairobi City, Kenya

PURPOSE OF THE JOB

Collaborate with medical clients, intermediaries, and medical service providers to facilitate access to quality, timely, effective, and cost-efficient healthcare services with the aim of achieving business growth, profitability, and customer retention.
Improve management and outcome of specified medical condition while containing cost for clients with newly diagnosed or long-standing medical conditions.
Client retention and satisfaction through promotion of self-management of medical condition and involvement in their care.
To achieve desired health outcomes and enhance quality of care for clients with specified chronic conditions.

KEY RESPONSIBILITIES

Care Management

Pre-authorize admission, discharges, scheduled and emergency medical cases, issue timely responses as per policy benefits and company guidelines.
Review patient’s history and records to determine cause of disease and assess if treatment correlates with the diagnosis and applicable benefits.
Coordinate local and international emergency evacuations, referrals, and transfers
Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration) and ensure their compliance.
Negotiate doctors’ and hospital bills and charges in view of reducing the cost of care before or during admissions.
Visit patients admitted within Nairobi and follow up the ones admitted outside Nairobi.
Follow through and resolve escalated customers and provider queries and complains in time and advisethem on outcome and the details of the medical product.

Chronic Disease Management

Early identification and assessment of members through periodic claims analysis for admittance / enrolment into the chronic disease management program
In conjunction with the Physician, proactively manage chronically ill members with the objective of improving quality outcomes and containing costs
Apply case management concepts, principles, and strategies in the development of an individualized case plan that addresses the member’s needs
Conducts regular discussions and updates with the member’s primary care physicians regarding the status and/or management of a particular member
Develop new programs as appropriate to reduce admissions for acute and chronic members and assist with decreasing their lengths of stay
In conjunction with the Physician, develops alternative healthcare methods that promote the provision of cost-effective healthcare and the preservation of the member benefits.
In coordination with provider relations, recruit healthcare providers and negotiate favourable wellness packages for members.
Prepare a drug formulary that is cost effective and ensures quality outcomes for our clients

Wellness and Medical Advisory

Coordinate member education, health talks, medical camps and other preventive care programs for members.
Identify and enroll members on the drug delivery program and in coordination with the healthcare providers ensure seamless delivery of the medication. Assist in scheme performance reviews and give recommendations with the aim of reducing the loss ratios.
Carry out risk assessment on members’ pre-joining medicals in coordination with the underwriting team and advise on appropriate measures.

Customer Service

Weekly, Monthly, and quarterly engagement with members through educative health articles and nuggets, preventive and curative care tips.
Conduct Post discharge follow-up calls for members to enhance customer service
Handle and resolve escalated customer service complaints from team members within 24 hours and escalate complex cases to the Manager

KNOWLEDGE AND EXPERIENCE
Academic Qualifications

Professional Qualifications

Experience:

Knowledge

SKILLS AND COMPETENCIES