Oversee and execute key duties, including [insert specific responsibilities], to ensure operational efficiency and strategic objectives are met. Develop, implement, and monitor processes to enhance productivity and maintain high standards of quality. Collaborate with cross-functional teams to align efforts with organizational goals and foster a cohesive working environment. Analyze performance metrics to identify areas for improvement and drive data-informed decision-making. Ensure compliance with industry regulations and company policies while managing resources effectively to optimize outcomes.
Care Management involves processing Outpatient, Optical, and Dental preauthorizations efficiently while maintaining clear and timely communication with providers, clients, and brokers regarding any undertakings, rejections, or pertinent concerns. Additionally, the role includes overseeing the 24-hour emergency line to ensure prompt response and resolution.
Oversee and execute essential duties including managing project timelines, coordinating team efforts, and ensuring alignment with organizational objectives. Lead cross-functional initiatives, allocate resources efficiently, and maintain clear communication channels to facilitate seamless operations. Monitor progress through regular evaluations, identify potential risks, and implement corrective measures to uphold productivity and performance standards. Serve as a liaison between departments, fostering collaboration to achieve shared goals. Ensure compliance with company policies, industry regulations, and quality benchmarks throughout all project phases.
Through meticulous due diligence, we ensure that undertakings are issued in strict accordance with policy provisions. Similarly, we diligently verify that decline decisions are both accurate and a precise interpretation of the policy guidelines.
Adhere to established turnaround times when issuing approvals to maintain efficiency and compliance with established protocols.
We require comprehensive medical clarifications, including medical reports and copies of investigation reports from healthcare providers, in accordance with established procedures.
Broker/customer relations involve timely communication of all pertinent claim decisions to clients.
Collaborate closely with the claims team to furnish any necessary details regarding claims submitted, ensuring adjustments are made when supplementary information alters the prior stance on the claim.
Engaging with clients, brokers, and providers as required, you will address concerns in a legally compliant, ethically sound, and policy-aligned manner to ensure resolution.
Facilitating discussions with providers to negotiate and finalize terms related to cost structures, including discounts, pre-established rates, bundled packages, fixed-price arrangements, and average cost agreements.
Ensure the system captures precise information and maintain a flawless record of benefit adjudication across all cases.
Facilitating communication and collaboration with the underwriting department to define and agree on the scope of coverage for multiple insurance schemes.
We collaborate closely with the provider relations team to address various provider-related matters, including panel management, customer complaints, and other relevant issues.
Managing the round-the-clock emergency helpline involves overseeing operations, ensuring seamless communication, and providing critical support to callers in urgent situations. This role requires vigilant monitoring of response protocols, coordination with emergency services, and maintaining accurate records of incidents. The position demands strong leadership to guide the helpline team, resolve escalations efficiently, and uphold compliance with established guidelines. Additionally, it entails analyzing call data to identify trends and enhance service delivery.
Strategic initiatives within the department will be executed, incorporating recommendations provided by the Claims Quality Assurance (QA) Committee.
Deliver a Net Promoter Score (NPS) benchmark across all customer service metrics.
Ensuring strict compliance with internal business processes, adhering to IRA regulations and guidelines, and upholding departmental work ethics is essential for the role.
Client presentations and member education initiatives are designed to promote prudent utilization and effective risk management, ensuring stakeholders remain well-informed and aligned with best practices.
Collaborate with the care management team to ensure all deliverables are completed within the specified timeframe.
Proficient candidates must demonstrate expertise in analytical thinking, problem-solving, and effective communication. A strong background in relevant technical or industry-specific methodologies is essential, along with the ability to adapt to evolving challenges. Prior experience in project management or cross-functional collaboration is highly valued. Proficiency with industry-standard tools and software is required, along with a commitment to continuous learning and professional development. Exceptional organizational skills and attention to detail are critical for success in this role.
Administers and oversees the entire spectrum of health benefits programs, ensuring alignment with organizational objectives, regulatory standards, and employee needs. Develops and implements benefit strategies, negotiates contracts with healthcare providers and insurers, and manages vendor relationships to secure optimal coverage at competitive rates. Conducts thorough analyses of benefit utilization, evaluates plan performance, and recommends enhancements to improve cost efficiency and participant satisfaction. Ensures compliance with federal, state, and local regulations while maintaining accurate records and documentation. Collaborates with HR, finance, and leadership teams to communicate benefit options, resolve employee inquiries, and facilitate seamless enrollment processes.
Policy interpretation involves analyzing and clarifying regulatory frameworks, legislation, and organizational policies to ensure accurate application and compliance. Professionals in this role assess complex legal and procedural documents, addressing ambiguities by consulting legislative intent, precedent, and stakeholder input. They develop clear, actionable guidance for stakeholders, ensuring alignment with legal requirements, operational objectives, and industry standards. Additionally, they may draft policy revisions, conduct impact assessments, and facilitate training to promote consistent understanding and adherence across teams. Strong analytical, communication, and legal research skills are essential, along with the ability to synthesize information from multiple sources to resolve intricate policy questions.
Providing exceptional client support and maintaining a strong customer-centric approach are central to this role. Demonstrating a commitment to understanding and addressing customer needs is essential, as is resolving inquiries efficiently and professionally. Strong interpersonal skills and the ability to communicate clearly with diverse audiences are required, along with patience and a problem-solving mindset. Prior experience in customer service or a related field is preferred, and proficiency with CRM systems and communication tools is advantageous. The ideal candidate will thrive in a fast-paced environment, consistently delivering high-quality service while fostering positive customer relationships.
We seek a dedicated professional to fulfill key responsibilities with unwavering commitment, ensuring all tasks are completed promptly and to the highest standards. This role requires a proactive approach, meticulous attention to detail, and the ability to manage multiple priorities efficiently. Candidates must demonstrate strong problem-solving skills, adaptability, and a collaborative mindset to support team objectives. Prior experience in a similar capacity is essential, along with proficiency in relevant tools and technologies. Excellent communication and organizational abilities are also vital to maintain seamless workflows and achieve organizational goals.
We pride ourselves on fostering a collaborative work environment where every team member feels valued and motivated to contribute their best. Strong interpersonal skills and a willingness to support colleagues are essential to thriving in our dynamic team setting. We seek individuals who embrace collective goals, actively engage in open communication, and demonstrate adaptability in tackling shared challenges together.
Excellent communication skills, both written and verbal, are essential for this role. Candidates must be adept at articulating complex ideas clearly and concisely to diverse audiences, including clients, team members, and stakeholders. The ability to tailor messaging to different contexts and ensure alignment with organizational goals is critical. Active listening, persuasive presentation, and professional correspondence are also required competencies for success in this position.
Proven capacity to manage multiple tasks simultaneously while maintaining attention to detail and meeting deadlines efficiently.
Exceptional proficiency in negotiation and decision-making is essential, along with the ability to analyze complex situations and arrive at well-informed, strategic choices.
Seeking a candidate with a robust educational background and relevant industry experience. The ideal applicant should possess advanced expertise in their field, demonstrated through a combination of formal education and practical work history. Proficiency in key technical skills and methodologies is essential, along with a proven track record of delivering measurable results in prior roles. Strong problem-solving abilities and adaptability to evolving industry trends are critical attributes for success in this position.
A minimum of two years of professional experience in case management or a closely related field is required.
Proficiency in overseeing patient admissions and discharges is required.
Academic and Professional Qualifications Needed
Earned a bachelor’s degree in either nursing or clinical medicine.
Applications must be submitted to the Group Human Resources Manager at Madison Group Limited, with the subject line referencing the position. Kindly send your application via email to hr_recruitment@madison.co.ke, ensuring it is received no later than Wednesday, 17th June 2026.
Qualifications
BA/BSc/HND
Experience Required
2 years
