Care Manager at Bristol Park Hospital

About the Position

We are seeking a qualified Care Manager to join our team at Bristol Park Hospital in Nairobi, Kenya. This role is central to coordinating patient care and managing authorization processes with insurance providers and payers.

Key Responsibilities

• Coordinate all inpatient and outpatient pre-authorization requests, extensions, and undertakings with payers
• Ensure timely submission, follow-up, and approval of pre-authorizations and extensions within required turnaround times
• Liaise with insurers, brokers, patients, and internal clinical teams to provide timely communication and clarification
• Validate and manage undertakings, guarantee of payments, and financial exposures for admissions and specialized procedures
• Ensure accuracy, completeness, and compliance of documentation and medical reports required by payers
• Review service validity, membership, and benefit coverage against payer rules and clinical standards
• Maintain accurate and structured records of authorization activities, including high-value cases
• Coordinate inward and outward referrals, ensuring complete documentation and seamless continuity of care
• Monitor trends, generate reports (daily, weekly, monthly), and identify gaps for continuous improvement
• Support interdepartmental communication to enhance timely service flow and customer experience
• Conduct capacity building for staff on appropriate billing and care coordination
• Uphold compliance with regulatory, ethical, and care quality standards

Essential Qualifications & Experience

• Bachelor's Degree in Nursing, Clinical Medicine, or related healthcare field
• Minimum 3 years' experience in one or more of the following:
  • Care coordination / Case management
  • Utilization review
  • Medical insurance liaison
  • Claims processing
  • Admission and discharge management
• Experience working with insurers, payers, and Third Party Administrators (TPAs)
• Proven ability to interpret medical documentation, reports, and treatment plans

Desirable Qualifications

• Certification in Case Management, Utilization Management, or Health Insurance
• Experience in referral coordination or clinical pathways