Care Manager

Role Purpose

The Care Manager is a clinically trained professional at the heart of ACS's medical operations function. The role carries three interconnected responsibilities: adjudicating pre-authorizations with speed and clinical accuracy, negotiating medical costs with healthcare providers during active admissions and service delivery, and providing sound clinical guidance to members navigating the healthcare system.

A particularly critical aspect of this role is the ability to step down care — identifying situations where a member can receive equivalent quality of treatment at a more cost-effective facility or care setting, and facilitating that transition in a way that is clinically safe, member-centred, and clearly communicated. The Care Manager must balance advocacy for the member's health outcomes with stewardship of scheme sustainability.

The ideal candidate is a clinically confident, commercially aware healthcare professional — typically a registered nurse or clinician with managed care experience — who can make sound, defensible clinical decisions under time pressure while maintaining strong relationships with providers, members, and internal teams.

Key Accountabilities

Care Coordination & Case Management

Coordinate and manage care plans for assigned members.

Conduct clinical assessments and evaluate members' healthcare needs.

Monitor admissions, ongoing treatment, referrals, and discharge processes.

Facilitate continuity of care across healthcare providers and service points.

Ensure timely escalation of critical and emergency cases.

Utilization Management

Review treatment plans to ensure appropriateness, quality, and cost-effectiveness.

Facilitate pre-authorizations and care approvals in accordance with clinical guidelines.

Monitor healthcare utilization and identify opportunities for cost containment.

Support interventions aimed at reducing unnecessary admissions and readmissions.

Provider & Stakeholder Engagement

Liaise with healthcare providers to coordinate member care and treatment plans.

Collaborate with internal teams to ensure seamless service delivery.

Participate in provider engagements, case reviews, and clinical discussions.

Foster positive relationships with members, providers, and other stakeholders.

Chronic Disease & Wellness Management

Monitor high-cost, chronic, and complex medical cases.

Support disease management and wellness initiatives.

Promote preventive healthcare and member education programs.

Guide members on available healthcare resources and treatment options.

Member Advocacy & Experience

Act as an advocate for members throughout their healthcare journey.

Provide guidance on benefit utilization and access to care.

Address member concerns and facilitate timely resolution of service issues.

Support initiatives aimed at improving member satisfaction and outcomes.

Clinical Quality & Compliance

Ensure adherence to clinical protocols, policies, and regulatory requirements.

Participate in clinical audits, quality reviews, and risk management activities.

Monitor quality indicators and recommend improvement initiatives.

Support implementation of evidence-based clinical practices.

Reporting & Documentation

Maintain accurate and up-to-date clinical records and case documentation.

Prepare care management, utilization, and case review reports.

Track and report on key care management metrics and outcomes.

Ensure confidentiality and proper management of member information.

Key Performance Indicators

Member Care Coordination

Quality of Clinical Outcomes

Case Management Effectiveness

Timeliness of Pre-Authorizations

Member Satisfaction

Care Plan Compliance

Hospitalization and Readmission Management

Utilization Management Effectiveness

Qualifications

Bachelor's Degree or Diploma in Nursing, Clinical Medicine, Medicine, Pharmacy or a related healthcare field.

Valid professional registration and licensing where applicable.

Added Advantage

Professional qualification in AIIK, ACII, or Certificate in Insurance.

Formal training in customer experience or call centre operations.

Knowledge of medical scheme operations, SLAs, and healthcare provider management.

Understanding of ISO Quality Standards and Data Protection Act compliance.

Experience

Minimum of 2 years' experience in case management, utilization management, clinical care, managed care, medical insurance, or healthcare administration.

Experience in a medical insurance, TPA, healthcare management, or managed care environment is preferred.

Knowledge of healthcare benefits, pre-authorizations, and clinical protocols.

go to method of application »

Minimum qualifications

BA/BSc/HND , Diploma , Professional Certificate

How to apply

Use the link(s) below to apply on company website.

Head of Finance

Head of Business Development

Senior Manager - ICT

Care Manager

Call Centre Executive (Clinical)

Client Success Executive

Provider Reconciliation Officer

Medical Claims Analyst

https://www.myjobmag.co.ke/apply-now/1375562

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