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Case Management Nurse
To control and manage medical benefit utilization through preauthorization and case management activities and ensure quality, appropriate cost effective care and good customer service
KEY TASKS AND RESPONSIBILITIES
- Pre-authorize scheduled and nonscheduled admissions within the set guidelines.
- Negotiate/discuss professional fees as appropriate for each admission.
- Set the appropriate parameters for each admission (claim reserve, initial authorized cost and duration).
- Visit all admitted clients within Nairobi region and its environs
- Liaise with Doctors on the day to day management of patients and obtain medical reports/ expected length of stay where indicated.
- Ensure smooth discharge process and co-ordinate any necessary post-hospitalization/ step down facility care.
- Revise reserves after discharge of member.
- Collect feedback from admitted clients on quality and scope of service by the service provider.
- Assist in carrying out verification and medical audit of claims/invoices before settlement.
- Develop and maintain monthly database on admissions, large claims and extended length of stay.
- Respond to queries from clients, intermediaries and service providers.
- Liaise with other medical underwriter for purposes of market surveys and 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 SP 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, KNOWLEDGE & EXPERIENCE
- Diploma or Degree in Nursing
- Diploma in Insurance/ COP
- Degree in Health systems Management/ Business management
- 1 years’ experience in clinical setting +1 years in insurance set up