Essential Job Details

• Position Title: Case Manager, Active Case Management
• Location: Nairobi, Kenya
• Employment Type: Full-Time
• Number of Vacancies: Not specified
• Salary: Not specified
• Category/Department: Health Insurance / Case Management
• Reporting To: Not specified
• Application Deadline: 28th June 2025
• Job Reference Number: JHIL180

Introduction

The Case Manager, Active Case Management role in Nairobi offers a dynamic opportunity for healthcare professionals to deliver impactful clinical oversight and ensure high-quality, cost-effective care for insured members requiring hospitalization. This position is ideal for individuals passionate about coordinating patient care, managing pre-authorizations, and aligning medical services with insurance policies to support both member health outcomes and the financial sustainability of medical schemes. By leveraging clinical expertise and strong analytical skills, the successful candidate will play a pivotal role in enhancing healthcare delivery across Kenya’s vibrant medical insurance landscape, ensuring timely and compliant care coordination.

About Jubilee Insurance

Jubilee Insurance is a leading provider of insurance solutions in Kenya, with a strong presence across East Africa. Operating in multiple counties, the organization is renowned for its commitment to delivering innovative and reliable health insurance products. With a focus on customer-centric services, Jubilee Insurance supports thousands of members by ensuring access to quality healthcare while maintaining financial prudence. The company has earned recognition for its operational excellence and dedication to improving community health outcomes, making it a trusted name in Kenya’s insurance sector.

Key Responsibilities

The Case Manager, Active Case Management will undertake a range of critical tasks to ensure seamless healthcare delivery and compliance with insurance protocols. Key responsibilities include:

• Evaluate inpatient pre-authorization requests to ensure clinical appropriateness and alignment with policy limits.
• Review medical reports and documentation to determine coverage eligibility and necessity of proposed treatments.
• Manage 24-hour nurse line operations on a shift basis to address member inquiries and urgent care needs.
• Verify membership eligibility and assess benefit scopes using scheme-specific records and databases.
• Authorize inpatient services, ensuring compliance with insurance policies and medical necessity.
• Liaise with underwriting and provider relations teams to clarify benefit structures and scheme terms.
• Respond to queries from clients, healthcare providers, and internal teams regarding coverage, claims, or treatment approvals.
• Maintain accurate and detailed records for all case-related transactions and decisions.
• Track turnaround times for approvals to ensure timely processing and communication with stakeholders.
• Support departmental Service Level Agreements (SLAs) and Key Performance Indicators (KPIs) through efficient case management.
• Conduct due diligence on all approvals and declines, ensuring decisions are well-documented and compliant.
• Vet undertaking requests for completeness, validity, and adherence to insurance documentation standards.
• Audit inpatient and outpatient claims to identify inconsistencies, potential fraud, or discrepancies.
• Confirm service validity by cross-referencing treatments, provider rules, and cost thresholds.
• Ensure all care management practices comply with national healthcare regulations and medical ethics standards.

These responsibilities require a proactive approach to balancing clinical excellence with operational efficiency, ensuring that the Case Manager, Active Case Management contributes to both patient satisfaction and organizational goals.

Qualifications and Skills

To excel in the Case Manager, Active Case Management role, candidates must meet the following qualifications and demonstrate key skills:

Required Qualifications

• Bachelor’s degree or Diploma in Nursing, Clinical Medicine, or a related field from a recognized institution.
• Professional Nursing Qualification (KRCHN) with a valid license from the Nursing Council of Kenya.
• Minimum of two (2) years of relevant experience in a medical insurance environment, focusing on inpatient care coordination, benefit administration, policy interpretation, or pre-authorization processes.
• Relevant certifications in case management, healthcare management, or clinical specialties.

Preferred Skills

• Clinical expertise: Strong ability to interpret medical reports, treatment plans, and clinical documentation.
• Health insurance knowledge: Deep understanding of insurance policies, benefit structures, and scheme operations.
• Case management proficiency: Demonstrated skills in utilization review and care coordination.
• Analytical thinking: Ability to make sound decisions based on clinical data and policy guidelines.
• Attention to detail: High accuracy in documentation, benefit adjudication, and claims processing.
• Communication skills: Excellent verbal and written communication for engaging clients, providers, and internal teams.
• Customer service orientation: Empathy and professionalism in addressing member and provider needs.
• Negotiation skills: Ability to manage relationships with healthcare providers and stakeholders effectively.
• Compliance knowledge: Familiarity with medical ethics, national healthcare regulations, and fraud prevention.
• Fraud detection: Skills in identifying and mitigating fraud, waste, and abuse in claims processing.
• Provider engagement: Experience in collaborating with healthcare providers is an added advantage.

These qualifications and skills ensure the Case Manager, Active Case Management can navigate complex healthcare and insurance environments while delivering exceptional service.

Company Culture and Values

Jubilee Insurance fosters a collaborative and inclusive work environment where employees are empowered to make a difference. The organization values accountability, transparency, and excellence, encouraging staff to take initiative while working in cross-functional teams to achieve shared goals. With a strong commitment to community health and sustainability, Jubilee Insurance promotes a culture of continuous learning and professional growth. Employees are supported through training programs and opportunities to contribute to impactful healthcare initiatives across Kenya.

How to Apply

Apply now for the Case Manager, Active Case Management position. Interested candidates should submit the following documents via email to Recruitment@jubileekenya.com, quoting Job Reference Number JHIL180 in the subject line:

• Updated CV
• Cover letter detailing your qualifications and experience
• Copies of relevant academic certificates and professional licenses

The application deadline is 28th June 2025. Only shortlisted candidates will be contacted. Jubilee Insurance is an equal opportunity employer committed to diversity and inclusion. For any inquiries, please contact the hiring company directly, as JobKenya.org is not the hiring entity and cannot process applications.

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Case Manager, Active Case Management, health insurance jobs in Kenya, Nairobi job vacancies, clinical case management, medical insurance careers

Detailed Role Overview

The Case Manager, Active Case Management position is a cornerstone of effective healthcare delivery within Kenya’s medical insurance sector. This role combines clinical expertise with operational efficiency to ensure that insured members receive timely, high-quality care while maintaining the financial integrity of the medical scheme. Based in Nairobi, the Case Manager will work closely with healthcare providers, underwriting teams, and members to facilitate seamless care coordination. By leveraging strong analytical and communication skills, the successful candidate will ensure that all inpatient services are authorized appropriately, claims are processed accurately, and member inquiries are handled with professionalism.

Why This Role Matters

In Kenya’s dynamic healthcare landscape, the Case Manager, Active Case Management plays a critical role in bridging the gap between clinical needs and insurance policies. This position ensures that members receive medically necessary treatments without unnecessary delays, while also protecting the scheme from financial risks such as fraud or overutilization. The role is particularly appealing to professionals who thrive in fast-paced environments and are passionate about making a tangible impact on patient outcomes. With Nairobi as the hub of operations, the Case Manager will engage with diverse stakeholders, from hospital administrators to insurance underwriters, to deliver exceptional service.

Key Operational Duties

The operational responsibilities of the Case Manager, Active Case Management are designed to ensure efficient and compliant care delivery. These duties include:

• Assess clinical documentation to confirm the medical necessity of proposed treatments, ensuring alignment with policy limits.
• Monitor inpatient admissions to track progress and ensure adherence to approved care plans.
• Coordinate with healthcare providers to clarify treatment plans and resolve discrepancies in claims.
• Process pre-authorization requests promptly to minimize delays in patient care.
• Document all decisions and communications in a clear, organized manner for audit purposes.
• Collaborate with internal teams to streamline processes and improve service delivery.
• Respond to urgent member inquiries through the 24-hour nurse line, providing accurate and empathetic support.
• Ensure timely communication of approval or denial decisions to all relevant parties.
• Track key performance metrics, such as turnaround times, to meet departmental goals.
• Support fraud prevention efforts by auditing claims for inconsistencies or irregularities.

These tasks require a keen eye for detail and the ability to balance clinical judgment with operational efficiency, making the Case Manager, Active Case Management a vital part of the healthcare ecosystem.

Compliance and Governance

Compliance is a cornerstone of the Case Manager, Active Case Management role. The successful candidate will ensure that all decisions adhere to national healthcare regulations, medical ethics, and insurance policy guidelines. Key governance responsibilities include:

• Review all claims and authorizations to ensure compliance with scheme-specific provisions.
• Document every decision with clear justifications to support audits and regulatory reviews.
• Identify potential fraud or abuse in claims through thorough analysis of treatment records and costs.
• Adhere to ethical standards in all interactions with members, providers, and colleagues.
• Maintain up-to-date knowledge of Kenya’s healthcare regulations and insurance industry standards.

By upholding these standards, the Case Manager ensures that the organization operates with integrity and transparency, fostering trust among members and stakeholders.

Career Growth Opportunities

The Case Manager, Active Case Management role offers significant opportunities for professional development. Candidates can expect to:

• Enhance their expertise in medical insurance operations and case management.
• Develop advanced skills in utilization review, fraud detection, and provider engagement.
• Gain exposure to cross-functional teams, including underwriting, provider relations, and claims processing.
• Contribute to impactful healthcare initiatives that improve community health outcomes.
• Access training and certification programs supported by Jubilee Insurance to advance their career.

This role is an excellent stepping stone for professionals aiming to advance into senior healthcare management or specialized insurance roles.

Why Nairobi?

Nairobi, Kenya’s bustling capital, is a hub for healthcare and insurance innovation. As the Case Manager, Active Case Management, you will be based in a vibrant city with access to leading hospitals, clinics, and insurance providers. Nairobi’s dynamic environment offers opportunities to network with industry leaders and contribute to transformative healthcare solutions. The role’s full-time nature ensures stability, while the opportunity to work with a reputable organization like Jubilee Insurance adds significant value to your professional portfolio.

Skills in Action

The Case Manager, Active Case Management role requires a unique blend of technical and interpersonal skills. For example:

• Clinical analysis: Reviewing a patient’s medical report to approve a surgical procedure while ensuring it aligns with policy limits.
• Provider negotiation: Collaborating with a hospital to adjust a treatment plan to fit within a member’s coverage.
• Customer service: Responding to a member’s inquiry about claim status with clarity and empathy.
• Fraud detection: Identifying discrepancies in a claim that suggest overbilling or unnecessary treatments.
• Time management: Balancing multiple pre-authorization requests to meet tight deadlines.

These skills ensure that the Case Manager delivers value to both members and the organization.

Application Tips

To stand out as a candidate for the Case Manager, Active Case Management role, consider the following:

• Tailor your CV to highlight relevant experience in medical insurance or case management.
• Emphasize your clinical qualifications, such as a KRCHN license or certifications in healthcare management.
• Include examples of successful case management or provider engagement in your cover letter.
• Ensure all documents are clear, concise, and free of errors.
• Submit your application before the 28th June 2025 deadline to avoid missing out.

By following these tips, you can increase your chances of securing this exciting opportunity.

Conclusion

The Case Manager, Active Case Management role is a unique opportunity to make a meaningful impact in Kenya’s healthcare and insurance sectors. By combining clinical expertise with operational excellence, the successful candidate will ensure that insured members receive high-quality care while maintaining the financial sustainability of the medical scheme. With a competitive application process and a deadline of 28th June 2025, now is the time to apply for this rewarding position in Nairobi. Join a dynamic team and contribute to improving healthcare outcomes across Kenya.