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Case Management Nurse

4 months ago

Nairobi, Nairobi Area, Kenya Old Mutual Full time

ABOUT THE COMPANY

Old Mutual Kenya provides investment, savings, life assurance, asset management, banking and property and casualty insurance in Africa, Europe, the Americas and Asia. We have over 17 million customers and approximately employees.

JOB SUMMARY

To control and manage medical benefit utilization through preauthorization and case management activities and ensure quality, appropriate cost-effective care and good customer serviceSKILLS AND COMPETENCIESExcellent communication and negotiation skills.Excellent public relations and interpersonal relationship skills.Extensive networking with SP and other medical insurers.Excellent analytical and monitoring skillsGood IT skills in database management and office systems.Good decision making in benefit utilization management. High levels of integrity and honestyQUALIFICATIONS, KNOWLEDGE & EXPERIENCEDiploma or Degree in Nursing Diploma in Insurance/ COPDegree in Health systems Management/ Business management 3 years' experience in clinical setting +2 years in insurance set up

RESPONSIBILITIES

Pre-authorize scheduled and non-scheduled 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 environsLiaise 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.

REQUIRED SKILLS

Negotiation, Nursing, Decision making, Communication, Interpersonal communication

REQUIRED EDUCATION

Diploma, Associate's degree