Care Manager - First Assurance Kenya

About the role

This position sits within a large African financial services group with a long operating history and a strong regional and international footprint. The role is part of a career development environment designed to help professionals grow with guidance, tools, and support.

The care manager works closely with health insurance clients, brokers, intermediaries, medical providers, and internal teams to help members access healthcare that is safe, timely, effective, and cost-conscious. The role also demands close attention to industry changes and consistent delivery against service, compliance, and quality targets.

What you will do

• Assess each case carefully and issue undertakings according to policy terms, ensuring approvals, declines, or partial approvals are accurate and aligned to the contract.
• Examine patient records and medical history to confirm the diagnosis, understand the cause of illness, and check whether proposed treatment matches the benefit entitlement.
• Authorize admissions, discharge processes, scheduled treatments, and emergency cases, providing responses within policy and company guidelines.
• Set and monitor admission controls such as claim reserve, initial approved amount, and duration, making sure they remain within approved limits.
• Visit admitted patients and conduct daily follow-ups to support good-quality care delivered at a reasonable cost.
• Meet turnaround time expectations when issuing approvals, letters of undertaking, and other written communication.
• Keep brokers, agents, corporates, and customer relations teams informed of admission and claim decisions promptly.
• Work with clients, brokers, and clinicians to resolve issues in a timely, ethical manner and in line with company policy and legal/regulatory requirements.
• Negotiate with providers, doctors, and hospitals on pricing, tariffs, discounts, pre-agreed rates, packages, and fixed-cost arrangements.
• Check the validity of services provided, including benefit coverage, treatment delivered, provider panel compliance, and treatment cost.
• Record information accurately in the system and maintain zero-error handling in benefit adjudication.
• Partner with teams such as provider relations, call center, claims, underwriting, and audit to resolve customer needs and deliver complete solutions.
• Deliver presentations and educate members on sensible benefit use and risk management.
• Review treatment plans for admitted patients daily, track improvement and bill growth, guide coverage decisions, and keep intermediaries updated.
• Handle escalated complaints and queries from customers and providers, and explain outcomes together with product details.
• Guide members toward cost-effective care options such as maternity packages and chronic care solutions.
• Support and help implement preventive care initiatives, including health talks, wellness activities, and the chronic disease management program.
• Identify opportunities to improve processes and introduce practical innovations that make operations more efficient.
• Prepare and send weekly and monthly reports covering admissions, exceptional claims, long-stay cases, savings, and related metrics.
• Protect client confidentiality and comply with the Data Protection Act.
• Carry out any additional duties assigned by the line manager.

Knowledge, reporting, and relationships

You are expected to continue building technical knowledge through self-learning, training, mandatory continuing professional education, coaching, and feedback. You will also share useful knowledge with colleagues and maintain strong working relationships with clients, brokers/agents, corporate HR teams, and internal colleagues.

Education and professional requirements

• A Bachelor’s Degree or Diploma in Nursing, Clinical Medicine, Health Management, or a similar field is required.
• You should have at least 2 years of clinical experience and 1 year of experience in case management.
• Professional registration with the relevant statutory regulator in your medical field is required.
• You must be a member of the relevant professional medical association and in good standing.
• Proficiency with Microsoft Office is needed.
• You should understand insurance policies, regulations, compliance, and standards.
• Strong communication, empathy, negotiation, problem-solving, adaptability, and customer-focused service skills are important.

Education note

Further Education and Training Certificate (FETC): Business, Commerce and Management Studies is listed as required.