Care Manager at Afia Concept Claims Settling Agency (ACS)

Key responsibilities

• Coordinate and manage care plans for assigned members.
• Conduct clinical assessments and evaluate members' healthcare needs.
• Monitor admissions, ongoing treatment, referrals, and discharge processes.
• Facilitate continuity of care across healthcare providers and service points.
• Ensure timely escalation of critical and emergency cases.
• Review treatment plans to ensure appropriateness, quality, and cost-effectiveness.
• Facilitate pre-authorizations and care approvals in accordance with clinical guidelines.
• Monitor healthcare utilization and identify opportunities for cost containment.
• Support interventions aimed at reducing unnecessary admissions and readmissions.
• Collaborate with internal teams to ensure seamless service delivery.
• Monitor high-cost, chronic, and complex medical cases.
• Support disease management and wellness initiatives.
• Promote preventive healthcare and member education programs.
• Provide guidance on benefit utilization and access to care.
• Support initiatives aimed at improving member satisfaction and outcomes.
• Ensure adherence to clinical protocols, policies, and regulatory requirements.
• Monitor quality indicators and recommend improvement initiatives.
• Support implementation of evidence-based clinical practices.

Candidate requirements

• Location Nairobi
• Job Field Medical / Healthcare &nbsp.
• Role Purpose
• The Care Manager is a clinically trained professional at the heart of ACS's medical operations function. The role carries three interconnected responsibilities: adjudicating pre-authorizations with speed and clinical accuracy, negotiating medical costs with healthcare providers during active admissions and service delivery, and providing sound clinical guidance to members navigating the healthcare system.
• A particularly critical aspect of this role is the ability to step down care — identifying situations where a member can receive equivalent quality of treatment at a more cost-effective facility or care setting, and facilitating that transition in a way that is clinically safe, member-centred, and clearly communicated. The Care Manager must balance advocacy for the member's health outcomes with stewardship of scheme sustainability.
• The ideal candidate is a clinically confident, commercially aware healthcare professional — typically a registered nurse or clinician with managed care experience — who can make sound, defensible clinical decisions under time pressure while maintaining strong relationships with providers, members, and internal teams.
• Key Accountabilities.
• Care Coordination & Case Management.
• Coordinate and manage care plans for assigned members.
• Conduct clinical assessments and evaluate members' healthcare needs.
• Monitor admissions, ongoing treatment, referrals, and discharge processes.
• Facilitate continuity of care across healthcare providers and service points.
• Ensure timely escalation of critical and emergency cases.
• Utilization Management.
• Review treatment plans to ensure appropriateness, quality, and cost-effectiveness.
• Facilitate pre-authorizations and care approvals in accordance with clinical guidelines.
• Monitor healthcare utilization and identify opportunities for cost containment.
• Support interventions aimed at reducing unnecessary admissions and readmissions.
• Provider & Stakeholder Engagement.
• Liaise with healthcare providers to coordinate member care and treatment plans.
• Collaborate with internal teams to ensure seamless service delivery.
• Participate in provider engagements, case reviews, and clinical discussions.
• Foster positive relationships with members, providers, and other stakeholders.
• Chronic Disease & Wellness Management.
• Monitor high-cost, chronic, and complex medical cases.
• Support disease management and wellness initiatives.
• Promote preventive healthcare and member education programs.
• Guide members on available healthcare resources and treatment options.
• Member Advocacy & Experience.
• Act as an advocate for members throughout their healthcare journey.

Required skills