Manages and oversees critical operational functions to ensure seamless workflow efficiency and adherence to established protocols. Responsible for coordinating cross-functional teams, monitoring performance metrics, and implementing process improvements to enhance productivity and meet organizational goals. Ensures compliance with industry regulations and internal policies while maintaining high standards of quality and accountability. Collaborates with senior leadership to develop strategic initiatives, allocate resources effectively, and drive sustainable growth. Requires a proactive approach, strong analytical skills, and the ability to adapt to evolving business demands while fostering a culture of innovation and continuous improvement.
Care Management involves processing Outpatient, Optical, and Dental preauthorizations while ensuring seamless communication with providers, clients, and brokers regarding undertakings, rejections, or pertinent concerns in a timely manner. Additionally, this role includes overseeing the 24-hour emergency line to address urgent matters promptly and efficiently.
Oversee and execute a comprehensive range of duties encompassing strategic planning, project management, and cross-functional collaboration to drive organizational objectives. Lead initiatives to enhance operational efficiency, implement best practices, and foster innovation across teams. Monitor performance metrics, analyze data trends, and provide actionable insights to senior leadership to inform decision-making. Ensure compliance with industry regulations and internal policies while maintaining high standards of quality and accountability. Serve as a liaison between departments, stakeholders, and external partners to facilitate seamless communication and alignment of goals. Develop and mentor team members through coaching, feedback, and professional development opportunities to cultivate a high-performing workforce.
Through meticulous due diligence, we ensure that undertakings are issued in strict accordance with policy provisions. Additionally, for declined applications, we verify that decisions are precise and reflect an accurate interpretation of the policy.
Maintain strict adherence to established turnaround times for the issuance of approvals.
The role requires obtaining medical clarifications, which includes requesting medical reports, as well as copies of investigation reports from healthcare providers, all in accordance with established protocols.
Maintain broker and customer relations by delivering all essential claim determinations to clients promptly.
Collaborate with the claims team to furnish any additional details needed for claims submissions, particularly when supplementary information alters the prior stance on a claim.
Interacting with clients, brokers, and providers as required, you will address issues while ensuring compliance with legal standards, ethical guidelines, and the policy’s underlying principles.
Negotiating with healthcare providers to establish cost-related terms, including discounts, pre-agreed rates, bundled pricing, fixed-fee arrangements, and average cost agreements.
Ensure all case information is accurately recorded in the system while maintaining a flawless benefit adjudication process, guaranteeing zero errors in every instance.
Serving as a liaison with the underwriting department, you will collaborate on defining the scope of coverage for multiple schemes.
The role involves collaborating with the provider relations department to address matters concerning the provider panel, as well as customer complaints.
Overseeing the round-the-clock emergency helpline operations, this role ensures continuous availability of critical support services. The position demands vigilant monitoring, prompt response to inquiries, and effective coordination with relevant stakeholders to address urgent situations efficiently. Responsibilities include maintaining accurate records, adhering to established protocols, and escalating cases as needed to ensure timely resolution. Strong communication skills, crisis management proficiency, and the ability to remain composed under pressure are essential to fulfilling this demanding yet vital function.
Strategic initiatives will be executed for the department, alongside recommendations provided by the Claims Quality Assurance (QA) Committee.
Drive all customer service metrics to achieve a Net Promoter Score (NPS) within the designated parameters.
Ensuring strict adherence to internal business processes, IRA regulations and guidelines, and maintaining high ethical standards are paramount responsibilities for this department.
Client presentations and member education initiatives focus on promoting prudent utilization strategies and effective risk management practices, ensuring informed decision-making and safeguarding stakeholders’ interests.
Collaborate with the care management team to guarantee timely completion of all deliverables within the specified turnaround time.
Proven expertise in relevant technical and interpersonal abilities, with a strong emphasis on analytical thinking, problem-solving, and effective communication. Demonstrated proficiency in specialized tools, methodologies, or industry-specific knowledge critical to the role. Exceptional organizational and time-management capabilities to prioritize tasks efficiently and meet deadlines consistently. A track record of adaptability and continuous learning to stay current with evolving trends and technologies. Strong collaboration skills to work seamlessly in team environments while fostering innovation and driving results. Commitment to maintaining high ethical standards and professional integrity in all aspects of work.
Oversee the strategic administration and operational execution of the organization’s health benefits program to ensure comprehensive coverage and cost-effectiveness. Develop, implement, and maintain policies, procedures, and systems to streamline enrollment, claims processing, and provider network management. Collaborate with insurance carriers, brokers, and internal stakeholders to negotiate contracts, secure favorable terms, and resolve escalated issues. Monitor regulatory compliance, track performance metrics, and analyze data to identify trends, mitigate risks, and optimize plan performance. Lead cross-functional initiatives to enhance employee satisfaction, control expenses, and align benefits offerings with organizational objectives and workforce needs.
Interprets and applies established policies, regulations, and directives to ensure alignment with organizational objectives and compliance standards. Analyzes complex policy frameworks to provide accurate guidance, resolve ambiguities, and address inquiries from stakeholders. Develops clear, concise interpretations to support decision-making processes and mitigate potential risks associated with policy misinterpretation. Collaborates with cross-functional teams to review policy updates, assess their impact, and recommend adjustments as necessary. Maintains thorough documentation of policy-related activities and ensures accessibility for relevant parties.
We prioritize exceptional customer service and maintain an unwavering focus on meeting client needs. Our team is dedicated to delivering prompt, courteous, and effective support, ensuring a seamless experience for all customers. By actively listening and addressing inquiries with precision, we foster trust and satisfaction while upholding the highest standards of professionalism. This commitment drives our ability to resolve issues efficiently and cultivate long-term relationships built on reliability and clarity.
We require a dedicated professional who demonstrates unwavering responsibility and commitment to their role. The ideal candidate will consistently prioritize tasks, meet deadlines, and maintain a high standard of work. They must approach challenges with diligence, adapt to changing priorities, and exhibit a strong work ethic. Reliability, accountability, and a proactive mindset are essential traits for success in this position.
Demonstrates a strong commitment to collaborative work environments, fostering unity, and encouraging mutual support among colleagues to achieve shared objectives. Exhibits enthusiasm, reliability, and active participation in group activities, ensuring a cohesive and productive team dynamic. Values diverse perspectives and promotes an inclusive atmosphere where every team member feels respected and valued.
Excellent interpersonal and written communication skills are essential, enabling effective engagement with colleagues, clients, and stakeholders across various levels. The ability to convey information clearly and professionally is crucial to fostering collaboration and ensuring alignment with organizational goals.
Demonstrated capability to manage multiple tasks simultaneously while maintaining efficiency and attention to detail. Proven ability to prioritize workloads, adapt to shifting priorities, and meet deadlines in fast-paced environments. Strong organizational skills and proficiency in balancing competing demands to ensure timely and accurate completion of assignments.
Demonstrates exceptional proficiency in negotiating terms and making well-informed decisions with a strategic mindset.
Demonstrated expertise and practical experience in the relevant field are essential. Candidates must possess a minimum of [X] years of professional experience in [specific industry/role], along with a comprehensive understanding of [key skills/technologies]. A proven track record of [specific achievements or responsibilities] is required, ensuring the ability to deliver results in a dynamic environment. Familiarity with [relevant tools, processes, or methodologies] is highly desirable, as is the capacity to apply theoretical knowledge to real-world challenges.
A minimum of two years of professional experience in case management or a closely related field is required.
Possesses proven experience in overseeing the admissions and discharge processes.
Academic and Professional Qualifications
Applicants must possess the necessary academic credentials and professional experience to meet the specified requirements for this role.
A bachelor’s degree in nursing or a clinical medicine-related field is required.
Applications must be submitted to the Group Human Resources Manager at Madison Group Limited via email at hr_recruitment@madison.co.ke by Wednesday, 17 June 2026.
Qualifications
BA/BSc/HND
Experience Required
2 years
