Case Manager, Active Case Management

You will deliver end-to-end clinical oversight and case management for insured members requiring hospitalization, ensuring they receive medically appropriate, high-quality, and cost-effective care. This role involves evaluating pre-authorizations, monitoring inpatient admissions, and coordinating with healthcare providers.

• Bachelor's degree/Diploma in nursing or clinical medicine, or a related field

• Professional Nursing qualification KRCHN licensed by Nursing council of Kenya

• Relevant certifications in case management, healthcare management, or clinical specialties

• Minimum of two (2) years of relevant experience in a similar or equivalent role within a medical insurance environment

• Demonstrated expertise in inpatient care coordination, insurance benefit administration, policy interpretation, and pre-authorization processes

• Experience in provider engagement will be an added advantage

• Clinical knowledge and ability to interpret medical reports and treatment plans

• Understanding of health insurance policies, benefits, and scheme structures

• Strong case management and utilization review skills

• Knowledge of compliance requirements, medical ethics, and healthcare regulations

• Ability to identify and mitigate fraud, waste, and abuse in claims