Primary Duties Include: Overseeing and executing key operational tasks to ensure seamless workflow efficiency. This encompasses monitoring progress, addressing challenges promptly, and aligning activities with organizational objectives. Additionally, the role demands active participation in strategic planning, fostering collaboration across departments, and maintaining rigorous compliance with established policies and industry standards.
Care Management involves overseeing preauthorization processes for Outpatient, Optical, and Dental services, while maintaining clear and prompt communication with providers, clients, and brokers regarding approvals, denials, or other pertinent matters. Additionally, the role encompasses managing the 24-hour emergency line to address urgent inquiries or concerns.
Oversee a diverse array of critical tasks encompassing strategic planning, operational execution, and team leadership, ensuring alignment with organizational objectives. Spearhead the development and implementation of initiatives designed to enhance efficiency, productivity, and overall performance metrics. Foster a collaborative work environment that encourages innovation, accountability, and continuous improvement among team members. Manage cross-functional projects, allocate resources effectively, and monitor progress to guarantee timely and high-quality deliverables. Act as a liaison between senior leadership and operational teams to facilitate clear communication and streamline decision-making processes. Ensure adherence to company policies, industry regulations, and best practices to mitigate risks and uphold compliance standards.
Care Management involves conducting thorough due diligence to ensure that undertakings align precisely with policy provisions. Additionally, for declined applications, it is essential to verify that decisions are both accurate and represent a correct interpretation of the policy.
Maintain strict compliance with established Turnaround Time protocols when issuing approvals.
We require comprehensive medical documentation, including medical reports and copies of investigation results from healthcare providers, as per established protocols.
Proactively convey all relevant claim resolutions to clients in a timely and professional manner, ensuring clear and effective communication of decisions regarding their claims.
Collaborate with the claims team to furnish any additional details needed for claims investigations, particularly when supplementary information alters the prior stance on a claim.
Engaging with clients, brokers, and providers as required, to address issues in compliance with legal, ethical, and policy-driven standards.
Facilitating discussions with providers to negotiate financial terms, including costs, discounts, pre-established rates, bundled packages, fixed-price agreements, and average-cost arrangements.
Ensure the system captures precise information and maintain a flawless adjudication process for all benefit cases, achieving a zero-error rate.
Collaborating closely with the underwriting department to define and refine the scope of coverage for multiple insurance schemes is a key responsibility.
The incumbent will collaborate with the Provider Relations department to address issues related to the provider panel and customer complaints.
Overseeing the 24-hour emergency helpline to ensure seamless operation and prompt response to critical inquiries.
The department’s strategic initiatives are executed, and recommendations provided by the Claims QA Committee are implemented as part of this role.
Drive all customer service metrics to meet or exceed Net Promoter Score (NPS) standards, ensuring consistent performance across key indicators.
To ensure alignment with established internal business procedures, IRA regulations, and ethical standards specific to the department, strict compliance is required.
Conduct client presentations and member training sessions to promote prudent use and risk mitigation strategies.
The role involves collaborating with the care management team to ensure all deliverables are completed within the specified turnaround time.
Proficiency in specific technical or soft skills pertinent to the role, including analytical capabilities, communication expertise, and problem-solving acumen, is essential. Candidates must demonstrate a strong understanding of industry standards, regulatory requirements, and compliance protocols relevant to the position. Exceptional organizational skills, attention to detail, and the ability to manage multiple priorities efficiently are critical. Familiarity with specialized tools, software, or methodologies relevant to the field is often required, along with a commitment to continuous learning and professional development. Strong interpersonal skills, teamwork orientation, and leadership potential may also be necessary, depending on the role’s demands. Prior experience in a similar capacity, as well as relevant certifications or educational qualifications, can significantly enhance a candidate’s suitability for the position.
The position involves overseeing and administering the organization’s health benefits program, ensuring compliance with regulatory standards and alignment with employee needs. Responsibilities include negotiating contracts with healthcare providers, managing claim processing, and analyzing plan performance to optimize cost efficiency and coverage quality. The role requires expertise in benefits administration, strong analytical skills, and proficiency in relevant software systems. Additionally, the individual will collaborate with HR and leadership to develop benefit strategies, communicate plan details to employees, and resolve complex benefit-related inquiries. A bachelor’s degree in a related field and several years of experience in benefits management are required, with certifications such as SHRM or CABS preferred.
Interpreting and applying regulatory guidelines, statutes, and organizational policies is a key responsibility of this role. The position requires a thorough understanding of legal frameworks and industry standards to ensure compliance and mitigate risk. Candidates must possess strong analytical abilities to assess complex policy documents and translate them into actionable insights. Experience in policy development, regulatory affairs, or a related field is essential, along with expertise in interpreting legislative changes and their implications. Proficiency in policy analysis tools and frameworks is also required, along with the capacity to communicate findings effectively to stakeholders at all levels.
Dedicated to delivering exceptional support and ensuring customer satisfaction, this role emphasizes a strong commitment to service excellence. It requires individuals who prioritize attentive listening, clear communication, and problem-solving skills to address inquiries and resolve issues efficiently. Candidates must demonstrate patience, adaptability, and a proactive approach to meeting customer needs while maintaining a professional demeanor in all interactions. Proficiency in handling multiple tasks, managing time effectively, and leveraging interpersonal skills to build rapport with clients is essential for success in this position.
We require a dedicated professional who demonstrates unwavering responsibility and a strong commitment to their role. The ideal candidate will prioritize reliability, ensuring tasks are completed accurately and on schedule while maintaining high standards of quality. They must exhibit a proactive approach, addressing challenges promptly and collaborating effectively with team members to achieve shared objectives. Consistency in performance, adherence to deadlines, and a willingness to go above and beyond are essential traits for this position.
Team Spirit
Excellent interpersonal and professional communication skills are essential for effectively collaborating with team members, clients, and stakeholders across various levels. The ability to convey ideas clearly, actively listen, and adapt messaging to different audiences is critical. Strong written communication, including the crafting of reports, emails, and presentations, is equally important. Candidates must demonstrate proficiency in both verbal and written communication to ensure seamless interaction and alignment within the organization.
Capable of effectively managing and prioritizing multiple tasks and responsibilities concurrently. Demonstrates strong organizational skills and adaptability to shifting priorities while maintaining high productivity and attention to detail.
Exceptional ability to negotiate effectively and make well-informed decisions.
We are seeking a candidate with a robust academic foundation and relevant professional experience. The ideal applicant will possess a deep understanding of industry-specific principles and practices, complemented by hands-on experience in their field. Additionally, they should demonstrate a proven track record in applying theoretical knowledge to practical scenarios, ensuring effective problem-solving and decision-making capabilities. Familiarity with current trends, methodologies, and tools within the domain is essential to excel in this role.
Minimum of two years of experience in case management or a related field is required.
Proven expertise in overseeing admissions and discharge processes.
Academic and Professional Qualifications Required
Applicants must possess the necessary academic credentials and professional experience as outlined in the specified requirements. A relevant degree from an accredited institution is essential, along with any certifications or licenses pertinent to the role. Additionally, candidates should demonstrate a proven track record of professional achievements that align with the position’s demands. Proficiency in industry-specific skills and adherence to professional standards are also mandatory.
A bachelor’s degree in nursing or a related field of clinical medicine is required.
Applications must be submitted to the Group Human Resources Manager at Madison Group Limited, using the email address hr_recruitment@madison.co.ke, ensuring receipt by Wednesday, 17th June 2026.
Qualifications
BA/BSc/HND
Experience Required
2 years
