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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: Supervisor Care Management – Outpatient and Call Centre
- 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 Supervisor Care Management will be responsible for overseeing Outpatient, Optical, and Dental pre-authorizations, ensuring timely communication with providers, clients, and brokers regarding undertakings, rejections, or other concerns. This role also involves managing the 24-hour emergency line and is directly accountable for achieving the targets of the Outpatient Care Management department.
Key Responsibilities
- Care Management: Exercise due diligence in issuing undertakings in line with policy provisions and ensure accurate decisions and correct policy interpretation for declines.
- Turnaround Time: Ensure appropriate Turnaround Time (TAT) is adhered to when issuing approvals.
- Medical Clarifications: Seek necessary medical clarifications, including medical reports and copies of investigation reports.
- Broker/Customer Relations: Communicate all necessary claim decisions to brokers and customers on a timely basis.
- Claims Coordination: Work with the claims team and coordinate on any information noted in claims, especially inpatient claims, where further information changes a previously undertaken position.
- 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 legal, ethical, and policy-consistent manner.
- Provider Engagement: Engage providers on matters concerning cost, discounts, pre-agreed rates, packages, fixed-cost models, and other contractual agreements.
- Membership & Benefits Check: Verify membership validity and benefits (from the scheme benefits file).
- Coverage Enquiries: Handle coverage inquiries from brokers, providers, members, and the general public.
- Service Vetting: Vet and confirm the validity of services rendered by providers in relation to covered benefits, treatment given, adherence to provider panel rules, and cost of treatment.
- Data Accuracy: Ensure accurate information is captured in the system and maintain a zero-error rate in the benefit adjudication of all cases.
- Information Gathering: Obtain additional required information on claims from providers, brokers, or clients.
- 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 the provider panel, customer complaints, etc.
- Client Education: Conduct client presentations and member education on wise utilization and risk management.
- Emergency Helpline: Manage the 24-hour emergency helpline.
- Team Support: Support the care management team to ensure all deliverables are met within the given turnaround time.
- Strategic Implementation: Implement strategic initiatives for the department and recommendations by the claims QA committee.
- Customer Service Metrics: Achieve an excellent NPS (Net Promoter Score) on all customer service indicators.
- Reporting: Ensure weekly QA reports are issued on all key indicators.
- Compliance: Ensure compliance with internal business processes, IRA Regulations/guidelines, and adherence to work ethics for the department.
- Staff Development: Engage in staff development, mentorship, and retention initiatives.
- Audit Resolution: Ensure the closure of any audit issues.
- Team Leadership: Lead the team in achieving the above responsibilities and departmental targets.
Contacts Arising from the Job (Key Relationships)
- Internal: All Staff and Intermediaries
- External: All Healthcare Service Providers, Customers, and Intermediaries
Skills and Competencies Required
- Health Benefits Plan Management
- Policy Interpretation
- Customer Service
- Team Management
- Cross-functional collaboration
- Excellent communication skills
Knowledge, Academic Qualifications & Work Experience
- BSc Nursing/Clinical Medicine or a relevant medical field.
- One year of experience in leading care management in health insurance.
- Experience in working in a medical call center.
Method of Application
Applications should be addressed to the Group Human Resources Manager, Madison Group Limited.
Email: hr_recruitment@madison.co.ke
The application should be received by Friday, May 30, 2025.
If you have a strong background in healthcare management, particularly within insurance and call center environments, and possess excellent leadership skills, consider applying for this pivotal role!
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