Old Mutual Kenya, a leading provider of long-term savings, asset management, and investment solutions, is seeking a Case Management Clinical Executive. This role is responsible for overseeing the clinical aspects of medical admissions and claim processing. The successful candidate will manage pre-authorizations for medical admissions, negotiate professional fees, visit admitted clients, and conduct medical audits of claims while ensuring adherence to established guidelines.
Key Tasks and Responsibilities
Pre-authorize scheduled and non-scheduled admissions within the set guidelines.
Negotiate and discuss professional fees as appropriate for each admission.
Set the appropriate parameters for each admission, including claim reserves, initial authorized cost, and duration.
Visit all admitted clients within the Nairobi region and its environs.
Liaise with Doctors on the day-to-day management of patients and obtain medical reports or expected length of stay estimates where indicated.
Ensure a smooth discharge process and coordinate any necessary post-hospitalization or step-down facility care.
Revise claim reserves after member discharge.
Collect feedback from admitted clients on the quality and scope of service provided by the service provider.
Assist in carrying out verification and medical audits of claims and invoices before settlement.
Develop and maintain monthly databases on admissions, large claims, and extended lengths of stay.
Respond to queries from clients, intermediaries, and service providers.
Liaise with other medical underwriters for market surveys and the development of new controls, standards, and products.
Any other duty assigned by management.
Skills and Competencies
Excellent communication and negotiation skills.
Excellent public relations and interpersonal relationship skills.
Extensive networking with service providers and other medical insurers.
Excellent analytical and monitoring skills.
Good IT skills in database management and office systems.
Good decision making in benefit utilization management.
High levels of integrity and honesty.
Qualifications and Experience
Diploma or Degree in Nursing.
Diploma in Insurance or Certificate of Proficiency (COP).
Degree in Health Systems Management or Business Management.
Minimum of 3 years’ experience in a clinical setting and 2 years in an insurance setup.
