The primary purpose of the Care Officer – Case Management role is to deliver clinical oversight and case management for insured members requiring hospitalization. You will be responsible for ensuring that members receive medically appropriate, high-quality, and cost-effective care, while also safeguarding the financial sustainability of the medical scheme. This includes evaluating pre-authorizations, monitoring inpatient admissions, and coordinating with healthcare providers. The position requires strong clinical acumen, a deep understanding of medical insurance operations, benefit structures, and regulatory requirements.
Duties and Responsibilities
Ensure proper care and treatment of patients within acceptable protocols to mitigate overuse of cover.
Vet and review claim documents to determine validity, eligibility, and benefits per policy guidelines.
Prepare daily reports of admissions across various service providers.
Resolve complicated and disputed cases at the call centre within agreed timelines.
Undertake timely claims processing within provider payment schedules.
Scrutinize pre-authorization forms for correct diagnosis and obtain additional information where required.
Undertake patient visits to ensure quality service, correct treatment, and eligibility.
Inform the provider management team of any anomalies in service or quality concerns.
Review and resolve complex cases providing appropriate clinical expertise on diagnosis and treatment.
Interact with clients, brokers, and clinicians to communicate admission claim decisions.
Liaise with the underwriting section for clarity on scope and omissions.
Support client presentations and member education on wise cover usage.
Academic and Professional Qualifications
Bachelor’s degree or Diploma in nursing, clinical medicine, or a related field.
Professional Nursing qualification (KRCHN) licensed by the Nursing Council of Kenya.
Relevant certifications in case management, healthcare management, or clinical specialties.
Experience
At least 3 years’ case management experience in a medical insurance environment.
Expertise in inpatient care coordination, insurance benefit administration, and pre-authorization processes.
Demonstrated knowledge of managing admissions and discharges.
Experience in provider engagement is an added advantage.
Technical and Behavioral Competencies
Clinical knowledge to interpret medical reports and treatment plans.
Understanding of health insurance policies, benefits, and scheme structures.
Strong analytical thinking and sound decision-making skills.
Knowledge of compliance requirements, medical ethics, and healthcare regulations.
Ability to identify and mitigate fraud, waste, and abuse in claims.
Agile mindset with the ability to manage tasks with competing deadlines.
High degree of emotional intelligence, integrity, and dependability.
How to Apply
If you meet the requirements and wish to be part of the vibrant team in the Health Department, please send your application letter and updated CV to the email address careers@gakenya.com by 11th February 2026. Interviews will be conducted on a rolling basis. Please indicate 'Care Officer – Case Management' in the email subject line. Only shortlisted candidates will be contacted.
