Index Page Prior Record Next Record Position:  CLINICAL CARE MANAGER -2 POSTS (FOR AN INTERNATIONAL MEDICAL INSURANCE SERVICE PROVIDER) Employer:  AN INTERNATIONAL MEDICAL INSURANCE SERVICE PROVIDER Ref No:  SGK-CM-08-2025 Industry:  INSURANCE Job Category:  SUPERVISORY Town:  NAIROBI Country:  KENYA Date Posted:  18/08/25 Deadline:  01/09/25 Requirements:  DEGREE IN NURSING OR CLINICAL MEDICINE OR RELATED FIELD. UNDERSTANDING OF INTERNATIONAL HEALTHCARE SYSTEMS AND INSURANCE BENEFITS. FAMILIARITY WITH INSURANCE TERMINOLOGY AND CLAIMS PROCESSES IS AN ADDED ADVANTAGE. STRONG ETHICAL STANDARDS AND COMMITMENT TO CLIENT CONFIDENTIALITY. ABILITY TO WORK ACROSS DIVERSE CULTURAL AND HEALTHCARE SYSTEMS. KNOWLEDGE OF AI-BASED HEALTHCARE MONITORING OR CLINICAL SUPPORT SYSTEMS IS A PLUS. Experience:  REGISTERED HEALTHCARE PROFESSIONAL (E.G., NURSING, CLINICAL OFFICER) WITH AT LEAST 2 YEARS OF EXPERIENCE. EXPERIENCE IN CASE MANAGEMENT, HOSPITAL COORDINATION, OR INSURANCE CARE ROLES PREFERRED. Salary:  KSHS. 80,000 - 120,000 PLUS COMPANY BENEFITS Additional Attributes:  THE CLINICAL CARE MANAGER IS RESPONSIBLE FOR COORDINATING AND OVERSEEING THE MEDICAL CARE JOURNEY FOR INSURED CLIENTS, ESPECIALLY DURING HOSPITALIZATION OR COMPLEX TREATMENT. THIS ROLE ENSURES CLIENTS RECEIVE APPROPRIATE (OR MEDICALLY NECESSARY), TIMELY, AND COST-EFFECTIVE CARE WHILE MAINTAINING HIGH-QUALITY SERVICE AND CLINICAL SUPPORT. THE CARE MANAGER WORKS CLOSELY WITH CLIENTS, HEALTHCARE PROVIDERS, AND INTERNAL TEAMS TO MANAGE CARE PLANS, MONITOR TREATMENT PROGRESS, AND GUIDE CLIENTS THROUGH THE HEALTHCARE SYSTEM BY PERFORMING THE FOLLOWING RESPONSIBILITIES:- ASSIST WITH PREAUTHORIZATIONS FOR MEDICAL SERVICES:- WORK WITH PHYSICIANS AND THE INSURERS MEDICAL REVIEW TEAMS TO OBTAIN REQUIRED PRE APPROVALS FOR TREATMENTS OR PROCEDURES. ENSURE ALL NECESSARY MEDICAL DOCUMENTATION IS SUBMITTED ON TIME AND APPROVALS ARE GRANTED BEFORE THE SERVICES ARE RENDERED. COORDINATE WITH HOSPITALS, DOCTORS, AND MEDICAL PROVIDERS:- COMMUNICATE PROACTIVELY WITH HEALTHCARE FACILITIES AND PROFESSIONALS TO GATHER TREATMENT PLANS, MEDICAL RECORDS, AND DISCHARGE SUMMARIES. CONFIRM THAT THE CARE BEING PROVIDED IS MEDICALLY NECESSARY, APPROPRIATE, AND ELIGIBLE FOR COVERAGE UNDER THE CLIENTS INSURANCE POLICY. SUPPORT CLIENTS AND THEIR FAMILIES THROUGH THE MEDICAL PROCESS:- ACT AS A KNOWLEDGEABLE POINT OF CONTACT FOR CLIENTS AND FAMILIES, HELPING THEM NAVIGATE COMPLEX MEDICAL SYSTEMS. PROVIDE CLEAR EXPLANATIONS ABOUT WHAT TREATMENTS ARE COVERED, HOW TO GET PRE APPROVALS, AND WHAT DOCUMENTATION IS NEEDED. OFFER GUIDANCE TO REDUCE CONFUSION AND STRESS DURING MEDICAL EVENTS. UTILIZE AI TOOLS AND CLINICAL DASHBOARDS:- OPERATE CARE MANAGEMENT SOFTWARE AND AI ASSISTED PLATFORMS TO STREAMLINE PROCESSING, DETECT INCONSISTENCIES, AND IMPROVE DECISION MAKING. STAY OPEN TO ADOPTING NEW TECHNOLOGIES THAT ENHANCE CARE MANAGEMENT HANDLING EFFICIENCY. MAINTAIN ONGOING COMMUNICATION WITH CLIENTS:- CHECK IN REGULARLY WITH CLIENTS DURING THEIR TREATMENT PROCESS THROUGH CALLS, EMAILS, OR WARD ROUNDS. KEEP THEM INFORMED ABOUT CLAIM STATUS, AUTHORIZATIONS, AND NEXT STEPS. BE EMPATHETIC AND CLEAR, ESPECIALLY WHEN EXPLAINING LIMITATIONS IN COVERAGE OR DELAYS IN PROCESSING. REVIEW MEDICAL REPORTS AND INVOICES FOR ACCURACY AND APPROPRIATENESS:- EXAMINE HOSPITAL BILLS, MEDICAL RECORDS, AND PROVIDER NOTES TO ENSURE TREATMENTS WERE DELIVERED AS CLAIMED AND WERE NECESSARY UNDER CLINICAL GUIDELINES. IDENTIFY ANY DISCREPANCIES, DUPLICATE BILLING, OR OVERCHARGES THAT MAY IMPACT COST CONTROL AND CLAIM INTEGRITY. SUPPORT CLAIMS AND UNDERWRITING TEAMS WITH MEDICAL INSIGHTS:- PROVIDE YOUR INTERNAL COLLEAGUES WITH MEDICAL CASE SUMMARIES, TREATMENT TIMELINES, AND INSIGHTS ABOUT POTENTIAL LONGTERM COSTS. YOUR EVALUATIONS HELP THE CLAIMS TEAM RESOLVE CASES FASTER AND ASSIST THE UNDERWRITING TEAM IN ASSESSING FUTURE RISK DURING POLICY RENEWAL OR ISSUANCE. IDENTIFY AREAS FOR IMPROVEMENT IN CARE COORDINATION:- AFTER A CASE IS CLOSED, EVALUATE THE PROCESS AND OUTCOMES. IDENTIFY DELAYS, CLIENT COMPLAINTS, OR MISCOMMUNICATIONS. USE THIS FEEDBACK TO PROPOSE IMPROVEMENTS IN CLAIMS WORKFLOWS, PROVIDER COORDINATION, OR CLIENT COMMUNICATION METHODS TO ENHANCE FUTURE CASE MANAGEMENT QUALITY. SGK reserves the right to shortlist: To apply for an advertised position, send your CV to recruit@skillsgeographic.com. If your CV is already in the SGK databank, DO NOT APPLY.