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Madison Group Limited is a respected Kenyan-owned financial services holding company. It specializes in insurance and wealth management, comprising Madison Life Assurance Kenya Limited, Madison General Insurance Kenya Limited, and Madison Investment Managers Limited. Madison Life Assurance Kenya, originally incorporated in 1988, has a rich history stemming from a merger between Crusader Plc (1974) and Kenya Commercial Insurance Corporation.
Job Overview
- Job Title: Senior Care Manager
- Location: Nairobi, Kenya
- Employment Type: Full Time
- Posted Date: May 26, 2025
- Application Deadline: Friday, May 30, 2025
- Salary: Not specified (compensation will be discussed by Madison Group Limited)
Overall Responsibility
The Senior Care Manager will be responsible for handling Inpatient pre-authorizations, ensuring timely communication with providers, clients, and brokers regarding undertakings, rejections, or relevant concerns. This role also involves comprehensive case management through physical visits and virtual follow-ups of all admitted members, and providing mentorship to the care managers within the team.
Key Responsibilities
- Care Management: Through due diligence, ensure undertakings are issued in line with policy provisions. Likewise, for declines, ensure that the decisions are accurate and a correct interpretation of the policy.
- Turnaround Time: Ensure appropriate Turnaround Time (TAT) is adhered to in issuing approvals.
- Medical Clarifications: Seek medical clarifications, including medical reports and copies of investigation reports.
- Broker/Customer Relations: Communicate all necessary admission claim decisions on a timely basis.
- Claims Coordination: Work with the claims team and coordinate any information noted in claims, especially inpatient claims submitted, where further information provided changes the position undertaken previously on the claim.
- Pre-authorization Review: Review medical pre-authorizations for compliance with applicable policy guidelines.
- Problem Resolution: Interact with clients, brokers, and clinicians as needed, to resolve problems in a manner that is legal, ethical, and consistent with the principles of the policy.
- Patient Engagement: Visit/engage admitted patients and ensure they receive quality and cost-effective care.
- Provider Engagement: Engage providers on matters concerning cost, discounts, pre-agreed rates, packages, and fixed-cost models.
- Membership & Benefits Check: Check and confirm membership validity and benefits (from the scheme benefits file).
- Coverage Enquiries: Handle coverage inquiries with brokers, providers, and members.
- Service Vetting: Vet and confirm the validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules, and cost of treatment.
- Information Gathering: Obtain additional required information on claims from providers, brokers, or clients.
- Data Accuracy: Ensure accurate information is captured in the system and maintain a zero-error rate in benefit adjudication of all cases.
- Internal Liaisons: Liaise with the underwriting section on the scope of cover for various schemes and with the provider relations section on matters pertaining to provider panel, customer complaints, etc.
- Client Education: Conduct client presentations and member education on wise utilization and risk management.
- Team Support: Support the care management team to ensure all deliverables are met within the given turnaround time.
Skills and Competencies Required
- Health Benefits Plan Management
- Policy Interpretation
- Customer Service and Focus
- Ownership & commitment
- Team Spirit
- Excellent communication
- Ability to multi-task
- Strong negotiation and decision-making skills
Knowledge & Work Experience
- At least 3 years’ case management experience in a medical insurance environment, with at least 2 years as a care manager.
- Demonstrated knowledge of managing admissions and discharges in a busy insurance company.
- Demonstrated experience in engaging service providers and doctors and negotiating cost.
- Demonstrated experience in case management reports, physical visits, and virtual follow-up of admitted cases.
Academic and Professional Qualifications Required
- Bachelor’s degree in Nursing or Clinical Medicine.
- At least two years’ experience in a care management role.
Method of Application
Applications should be addressed to the Group Human Resources Manager, Madison Group Limited.
Email: hr_recruitment@madison.co.ke
Applications should be received by Friday, May 30, 2025.
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