ABOUT CAREPAY
In 2015, the CarePay platform launched the mobile health wallet under the brand M-TIBA in Kenya. Combining mobile technology and -money so people could save up for future hospital expenses. Since then the platform grew to become the digital connector between the healthcare payers, providers, and members. Covering the end-to-end health insurance journey while always keeping the individual's perspective in mind first. The platform improves the way money flows through the healthcare system, lowering the costs society must pay to get access to good quality healthcare. CarePay is at the forefront of revolutionary technological and social impact within healthcare, improving the lives of millions around the world.
PURPOSE OF THE ROLE:
The Case Manager will be responsible for coordinating and managing inpatient and outpatient preauthorization requests in line with policy guidelines, clinical appropriateness, and cost containment objectives. The role holder will ensure timely review and authorization of medical requests, effective follow-up of admitted members through hospital visits and phone calls, and close monitoring of patient progress to support quality, medically necessary, and cost-effective care.
The Case Manager will oversee inpatient admissions from preauthorization through discharge, including reviewing interim bills, medical reports, treatment plans, and discharge summaries to ensure appropriateness of care, length of stay management, and alignment with benefit limits and policy terms. The role also involves engaging providers, members, and internal stakeholders to facilitate timely care decisions, manage escalations, and promote positive clinical and financial outcomes.
In addition, the Case Manager will identify utilization trends, potential fraud, waste and abuse indicators, and areas for process improvement, while contributing to reporting, service quality, and enhanced customer experience.
Preauthorization Management
- Review and assess inpatient and outpatient preauthorization requests in line with policy terms, clinical guidelines, and turnaround times.
- Approve, decline, extend, or amend preauthorizations based on medical necessity, eligibility, and benefit limits.
- Escalate complex, high-cost, or non-covered cases for further review.
Inpatient Case Management
- Manage inpatient admissions from preauthorization to discharge.
- Follow up admitted patients through hospital visits, calls, and provider engagement.
- Monitor patient progress, length of stay, and discharge plans.
Bill Review and Cost Control
- Review interim and final bills, medical reports, and treatment notes for clinical appropriateness and cost-effectiveness.
- Identify unnecessary admissions, prolonged stays, overbilling, or non-contracted charges.
- Flag fraud, waste, abuse, and cost-saving opportunities.
Stakeholder Coordination
- Liaise with hospitals, clinicians, members, and relatives to obtain updates and support timely decisions.
- Work with internal teams to resolve case-related issues and escalations.
- Provide timely feedback on case progress and authorization decisions.
Documentation and Reporting
- Maintain accurate case records, clinical notes, and authorization decisions in the system.
- Prepare reports on admissions, high-cost cases, prolonged stays, and utilization trends.
- Ensure confidentiality and compliance in all case documentation.
Quality and Process Improvement
- Identify cases needing closer management, including chronic, surgical, neonatal, and repeat admissions.
- Support service improvement through trend analysis, process review, and operational recommendations.
EDUCATIONAL QUALIFICATIONS, KNOWLEDGE & EXPERIENCE:
- Degree or Diploma in Nursing, Clinical Medicine, or another related health qualification from a recognized institution.
- Valid registration with the relevant professional regulatory body in Kenya.
- Minimum of 2–4 years experience in medical case management, utilization review, or claims assessment within the health insurance industry, hospital setting, or managed care environment.
- Certificate in Insurance (Mandatory).
- Good understanding of health insurance operations, preauthorization processes, and benefit application.
- Good knowledge of inpatient care pathways, treatment protocols, medical billing practices, and hospital workflows.
- Understanding of private and public healthcare systems in Kenya.
- Experience in reviewing medical reports, treatment plans, and hospital bills will be an added advantage.
SKILLS AND COMPETENCIES:
- Good analytical and problem-solving skills
- Excellent oral and written communication skills
- Strong interpersonal skills with ability to work with cross-cultural and diverse people and teams.
- Collaboration and team working skills.
- Customer service skills
- Data Entry skills with the ability to produce accurate work.
- Reporting and good attention to details
- Ability to prioritize and work to meet deadlines.
- Flexible and ability to adapt or change to new situations and handle high levels of uncertainty.
- Ability to maintain confidentiality.
CarePay is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to age, ancestry, color, family, gender identity, genetic information, marital status, race, religion or any other characteristic protected by applicable laws, regulations and ordinances.
