Analyst, Care Management

Location: Nationwide, Kenya
Job Type: Full Time
Industry: Health Insurance / Healthcare
Posted: Ongoing
Status: Application Deadline – 29th December 2024

About Heritage:

Heritage is a leading company in the healthcare and insurance industry, committed to providing high-quality services to our clients. We are an equal opportunity employer and value diversity in our workforce. We encourage individuals who meet the qualifications and possess the required experience to apply.

Key Responsibilities:

As an Analyst, Care Management, you will play a crucial role in ensuring the efficient handling of medical claims and providing exceptional care management for our clients. Your key responsibilities include:

• Maintain constant contact with hospitals to ensure continuous well-being of all stakeholders and handle medical claims with efficiency and accuracy.

• Pre-authorize scheduled and non-scheduled admissions within set guidelines.

• Liaise with hospitals and doctors for the prompt discharge plan of admitted members.

• Assess and authenticate inpatient and outpatient medical claim documents.

• Ensure smooth discharge processes and coordinate necessary post-hospitalization care.

• Prescreen and vet inpatient, outpatient, and reimbursements claims to ensure adherence to agreed tariffs and clinical protocols, including documenting declines and discounts offered by providers.

• Conduct hospital visits and monitor inpatient bills.

• Monitor interim bills daily and provide appropriate interventions for high-quality care.

• Provide daily status reporting on the clinical status of admitted members.

• Manage the contact centre, handle pre-authorization approvals, and respond to member and provider inquiries.

• Ensure timely notification to the team regarding declined cases as per policy guidelines.

• Resolve all client complaints promptly.

• Respond to all client and provider requests within 24 hours.

• Ensure all counter-guaranteed and roaming cases have official letters before approval.

• Authorization of maternity bookings and wellness letters within 24 hours.

• Monitor clients with chronic diseases by ensuring proper follow-up care is managed.

• Conduct health talks, wellness check-ups, and manage relationships with providers and stakeholders.

• Foster the Treating Customers Fairly (TCF) culture.

• Comply with governance requirements, including KYC, AML, and Data Protection regulations.

Qualifications:

• Educational Requirement: Bachelor’s Degree or Diploma in Nursing, Clinical Medicine, Pharmacy, or any medical-related discipline.

Experience:

• Minimum of 2 years of experience in the medical insurance, hospital, or related industry.

Competencies:

• Solid understanding of health insurance operations and concepts.

• Knowledge of medical claims processes and procedures.

• Excellent provider and stakeholder management skills.

• Strong analytical, customer service, and problem-solving skills.

• Ability to deliver results and meet customer expectations.

• Ability to cope with pressure and setbacks.

• Strong planning, organizing, and communication skills.

• Ability to adapt and respond to change.

• Proficient in learning and researching.

• Adherence to principles and values.

• Achieving personal work goals and objectives.

Application:

If you meet the above qualifications and experience, please send your application along with your updated CV to vacancies@heritage.co.ke by 29th December 2024. Be sure to include the job title in the subject line.

Heritage is an equal opportunity employer and encourages diversity in its workforce. Please note that only shortlisted candidates will be contacted. Your personal data will be handled in accordance with our privacy statement, available on our website: Heritage Careers.

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