Primary duties entail overseeing and executing key operational tasks, ensuring adherence to organizational standards and deadlines. Responsibilities include managing cross-functional teams, coordinating project timelines, and facilitating communication among stakeholders. Additionally, the role requires analyzing performance metrics, identifying inefficiencies, and implementing strategic improvements to enhance productivity and efficiency. Candidates must possess proven leadership experience, exceptional problem-solving abilities, and proficiency in relevant software tools. A bachelor’s degree in a related field or equivalent professional experience is preferred, along with strong interpersonal skills to foster collaboration and drive results.
The role involves overseeing Care Management processes, including preauthorization requests for Outpatient, Optical, and Dental services, while ensuring timely communication with providers, clients, and brokers regarding actions taken, denials, or related issues. Additionally, the position requires managing the 24-hour emergency line.
Oversee a comprehensive range of duties encompassing strategic planning, operational execution, and performance evaluation to ensure organizational objectives are met with precision and efficiency. Develop, implement, and monitor policies, procedures, and systems that enhance productivity, compliance, and accountability across all departments. Collaborate with cross-functional teams to align resources, streamline workflows, and drive continuous improvement initiatives. Lead performance assessments, provide constructive feedback, and foster a culture of accountability and professional growth. Ensure adherence to regulatory standards, industry best practices, and internal governance frameworks while maintaining robust risk management protocols.
Care Management involves conducting thorough due diligence to guarantee that undertakings are issued in strict alignment with policy provisions. Additionally, for cases involving declines, the role requires verifying that decisions are both accurate and correctly interpreted based on policy guidelines.
Maintain strict adherence to established Turnaround Time guidelines when processing and issuing approvals.
Seeking to obtain medical clarifications by gathering medical reports and copies of investigation reports from healthcare providers, in accordance with established protocols.
Facilitating broker and customer relations involves promptly conveying all essential claim decisions to clients in a timely manner.
Collaborate with the claims team to furnish any additional details needed for submitted claims, particularly when new information alters the stance previously adopted regarding the claim.
As required, liaising with clients, brokers, and providers to address issues in compliance with legal standards, ethical guidelines, and policy principles.
Develop and negotiate cost-related arrangements, including discounts, pre-established rates, bundled packages, fixed-cost agreements, and average-cost arrangements with providers.
Ensure the precise entry of information into the system while maintaining error-free benefit adjudication across all cases.
Facilitating communication and collaboration with the underwriting department to define and clarify the scope of coverage for multiple programs.
Liaising with the provider relations team 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.
Strategic initiatives within the department will be executed, alongside recommendations put forth by the Claims Quality Assurance Committee.
Strive to attain a Net Promoter Score (NPS) benchmark across all customer service metrics.
Professional Rewrite:
Ensuring strict compliance with internal business processes, IRA regulations and guidelines, as well as upholding the department’s ethical standards, is essential for this role.
Client presentations will be delivered, and member education initiatives will be conducted to promote prudent utilization and effective risk management strategies.
Collaborate with the care management team to guarantee the timely completion of all deliverables within the specified turnaround period.
Demonstrated proficiency in a range of technical and interpersonal abilities, alongside a proven track record in relevant fields, is essential. Candidates must exhibit strong analytical thinking, adaptability to evolving environments, and exceptional problem-solving capabilities. Familiarity with industry-standard tools and methodologies is required, as is the ability to collaborate effectively within cross-functional teams. Previous experience in a similar role and a commitment to continuous professional development are also necessary.
Manages the administration and strategic oversight of health benefits plans, ensuring compliance with regulatory standards and alignment with organizational objectives. Oversees the design, implementation, and maintenance of comprehensive health benefit programs, including medical, dental, vision, and wellness initiatives. Evaluates vendor performance, negotiates contracts, and monitors service delivery to optimize cost efficiency and participant satisfaction. Collaborates with HR, finance, and leadership teams to analyze utilization trends, forecast budgetary needs, and recommend enhancements to benefit offerings. Ensures accurate enrollment, claims processing, and adherence to legal requirements such as ERICA, ACA, and HIPAA. Provides guidance to employees on benefit options, eligibility criteria, and utilization of available resources. Tracks key performance indicators (KPIs) to assess program effectiveness and identify opportunities for continuous improvement.
Interprets and clarifies policies to ensure compliance with regulatory standards and organizational guidelines. Analyzes complex policy documents to identify key provisions and their implications for operations. Addresses inquiries from stakeholders regarding policy applications and resolves discrepancies through thorough research and consultation. Collaborates with cross-functional teams to align policies with business objectives while mitigating risks. Maintains up-to-date knowledge of industry regulations and updates policies as necessary to reflect changes in legal or operational requirements.
Dedicated to delivering exceptional support and prioritizing client satisfaction, we seek a professional who excels in interpersonal communication and problem resolution. The ideal candidate will demonstrate proficiency in handling inquiries, addressing concerns, and fostering positive customer relationships through attentive service. Strong organizational skills and adaptability are essential to manage diverse customer needs efficiently. Collaboration with cross-functional teams is also required to ensure seamless service delivery and continuous improvement in customer experience.
We are seeking a dedicated professional who can demonstrate unwavering responsibility and a strong commitment to their role. This position demands a high level of accountability, ensuring all tasks are completed with precision and timeliness. The ideal candidate will exhibit a proactive approach, maintaining focus on long-term goals while adapting to evolving priorities. Reliability and consistency in performance are essential, as the role requires adherence to deadlines and the ability to meet or exceed expectations. Additionally, the candidate must demonstrate a genuine dedication to continuous improvement and professional growth within the organization.
Team spirit is the driving force behind our collective success, fostering a collaborative and supportive work environment where every individual’s contributions are valued. At our organization, we seek candidates who not only possess the necessary technical skills and qualifications but also demonstrate a strong ability to work effectively within a team. The ideal candidate will exhibit a proactive attitude, adaptability, and a commitment to shared goals, ensuring seamless cooperation across departments. Responsibilities include actively participating in team discussions, offering constructive feedback, and supporting colleagues to achieve project objectives. We prioritize individuals who thrive in dynamic settings, embrace diverse perspectives, and contribute positively to our culture of mutual respect and achievement.
Excellent interpersonal and written communication skills are essential for fostering collaboration and conveying ideas effectively. Strong verbal articulation and active listening capabilities enable clear exchanges of information, ensuring alignment with team objectives and stakeholder expectations. Proficiency in crafting concise, persuasive messages across various formats—such as emails, reports, and presentations—demonstrates professionalism and clarity in every interaction.
Proven capability to prioritize and manage multiple tasks efficiently within demanding environments, ensuring deadlines are consistently met while maintaining high standards of quality and accuracy. Demonstrated adaptability in fast-paced settings with shifting priorities, balancing competing demands without compromising performance or attention to detail.
Exceptional proficiency in negotiation and decisive judgment is essential for this role. The ideal candidate will demonstrate a keen ability to navigate complex discussions and arrive at well-informed conclusions promptly.
Experienced professionals in the field are required to possess a comprehensive understanding of the subject and relevant work experience. Candidates should demonstrate proficiency in the core principles and practical applications of the role. Familiarity with industry standards, best practices, and emerging trends is essential for success. Additionally, a proven track record in similar positions or related fields is highly desirable.
A minimum of two years of hands-on experience in case management or a closely related field is required.
Proven expertise in overseeing the entire process of patient admissions and discharges.
Academic and Professional Qualifications Needed
A bachelor’s degree in a relevant field is mandatory, with a preference for advanced degrees in education, administration, or a closely related discipline. Relevant professional certifications or license may be required, depending on the specific role. Additionally, a minimum of five years of progressive work experience in an educational or administrative setting is essential. Demonstrated expertise in curriculum development, program management, and strategic planning is highly valued.
Earned a four-year degree in nursing or clinical medicine from an accredited institution.
Applications must be submitted to the Group Human Resources Manager at Madison Group Limited via email at hr_recruitment@madison.co.ke by Wednesday, 17th June 2026.
Qualifications
BA/BSc/HND
Experience Required
2 years
