Case Management Officer at Aga Khan Hospital Kisumu

Job Description

The position

CASE MANAGEMENT OFFICER

Reporting to the Assistant Claims Manager the successful candidate will proactively oversee clinical care plans, utilization, and treatment protocols during active patient care while ensuring all medical claims are accurately audited, ICD-10 coded, and verified prior to dispatch. He/She will be a vital bridge between clinical care and hospital financial operations—liaising with corporate/insurance clients, attending physicians, and internal billing teams to resolve clinical queries, clear discharge documentation, and establish strict controls that minimize claims rejections and revenue loss in line with the institution’s finance policy.

RESPONSIBILITIES:
Care Management

• Active Care & Authorization Oversight: Monitors patient care in real time—tracking length of stay, clinical necessity, and treatment plans while securing pre-authorizations and limit extensions on scheme portals before charges accumulate.
• Proactive Financial & Scheme Alignment: Inform clinical teams and patients early on policy exclusions, limits, and co-pays to set clear expectations and prevent billing disputes at discharge.
• Liaison & Care Transition: Acts as the primary clinical link between attending doctors, hospital staff, and corporate/insurance case managers. Ensures smooth, fully coded billing clearance at discharge.
• Utilization & Quality Assurance: Audits treatment patterns to curb over-utilization (unnecessary drugs or duplicate tests) and ensures care adheres to standard clinical protocols.

Verification of claims before processing for dispatch to corporate clients.

• Check if diagnosis is matching drugs issued and investigations.
• Highlight and identify exclusions from corporate (in terms of prescribed drugs) and implement ways of reducing such rejections before claims are dispatched.
• Signing on behalf of the doctor where the signature is missing.
• Filling of claim forms on invoices without claim forms.
• Work with the dispatch section to verify claims before they are dispatched.

Reconciliation on Rejections regarding clinical issues and other returned invoices.

• Monitoring invoice returns and taking appropriate action within a week from the date of return on clinical issues and any query.
• Take a lead in ensuring the reasons for returns are well addressed to avoid future recurrence.
• Preparing Rejection analysis on clinical issues and monthly reports as a tool to guide the institution on the status of control.
• Work with the Debtors team to review all the Clinical issues within the reconciliation to sign off for the agreed period with corporate clients.
• Facilitate closures to all rejected invoices on medical issues.

ICD-10 coding of claim forms

• Develop proficiency in and familiarize oneself with the ICD-10 coding system and coding tools.
• Develop proficiency in and familiarize oneself with insurance scheme platforms, including Smart, Slade, LCT, M-TIBA, and other relevant platforms.
• Develop proficiency in and familiarize oneself with CareWeb ICD Voucher Wise ICD entry and coding procedures.
• Ensure 100% of insurance claim forms requiring ICD-10 coding in CareWeb ICD Voucher Wise are collated, accurately coded, and completed within the stipulated turnaround time.
• Ensure 100% of insurance claim forms requiring ICD-10 coding on insurance scheme platforms are collated, accurately coded, and completed within the stipulated turnaround time.
• Aggregate, review, and follow up on claims with missing or incomplete diagnoses on a daily and weekly basis to facilitate timely and accurate coding and submission.
• Participate in all team efforts as departmental needs arise.
• Perform other duties as may be assigned by the Manager.

The requirements

• Diploma in Clinical Medicine or equivalent from a recognized institution
• Current practicing Certificate
• Membership registration to the relevant professional body.
• A minimum of 3 years’ relevant experience in a busy Hospital or Insurance
• Results-driven, ethical and adaptable professional with a strong service and stakeholder focus.
• Strong integrity with a sensitivity to manage confidential information.