Case Manager, Active Case Management at Jubilee Insurance

Job Ref. No: JHIL193
Position: Case Manager, Active Case Management

Jubilee Insurance was established in August 1937 as the first locally incorporated insurance company based in Mombasa. Over the years, Jubilee Insurance has expanded its reach throughout the region, becoming the largest composite insurer in East Africa, offering Life, Pensions, General, and Medical Insurance. With a client base of over 1.9 million, Jubilee stands as the number one insurer in East Africa. We operate a network of offices in Kenya, Uganda, Tanzania, and Burundi, and we are the only ISO-certified insurance group listed on the three East African stock exchanges – The Nairobi Securities Exchange (NSE), Dar es Salaam Stock Exchange, and Uganda Securities Exchange. For more information, visit www.JubileeInsurance.com.

We currently have an exciting career opportunity for a Case Manager, Active Case
Management, within Jubilee Health Insurance Limited. The position holder will report to the Assistant Manager, Active Case Management and will be based at our Head Office in Nairobi.

Role Purpose
The primary purpose of the Case Manager, Active Case Management is to deliver end-to-end clinical oversight and case management for insured members requiring hospitalization. The role is responsible for ensuring that members receive medically appropriate, high-quality, and costeffective care, while also safeguarding the financial sustainability of the medical scheme. This includes evaluating pre-authorizations, monitoring inpatient admissions and coordinating with healthcare providers. The position requires strong clinical acumen, a deep understanding of medical insurance operations, benefit structures, and regulatory requirements.

Main Responsibilities
Operational
1. Make timely decisions on inpatient pre-authorizations and undertakings in line with policy limits and clinical appropriateness.
2. Review medical reports and documents to determine coverage and need for treatment.
3. Manage 24-hour nurse line operations on a shift basis to support round-the-clock member needs.
4. Verify membership eligibility and assess scope of benefits using scheme-specific records.
5. Vet and authorize inpatient services
6. Liaise with underwriting and provider relations teams to ensure accurate interpretation of benefits and scheme terms.
7. Provide responses to client, provider, and internal queries regarding coverage, claim status, or treatment approvals.
8. Maintain accurate records for all case-related transactions.
9. Track turnaround time for all approvals and ensure timely processing and communication of decisions.
10. Support the team in meeting departmental SLAs and KPIs.

Corporate Governance
1. Ensure all inpatient authorizations and claims are reviewed and processed in strict adherence to policy provisions and regulatory guidelines.
2. Conduct thorough due diligence on approvals and declines, documenting all decisions accurately and consistently.
3. Vet all undertaking requests for completeness, validity, and compliance with insurance documentation standards.
4. Audit inpatient and outpatient claims to identify inconsistencies or potential fraud.
5. Confirm service validity against treatment given, provider rules, and cost thresholds.
6. Ensure all care management practices align with national healthcare regulations and medical ethics.

Key Competencies
1. Clinical knowledge and ability to interpret medical reports and treatment plans
2. Understanding of health insurance policies, benefits, and scheme structures
3. Strong case management and utilization review skills
4. Analytical thinking and sound decision-making based on clinical and policy guidelines
5. Attention to detail and accuracy in documentation and benefit adjudication
6. Excellent communication and interpersonal skills for engaging clients, providers, and internal teams
7. Customer service orientation with empathy and professionalism
8. Negotiation and relationship management skills with service providers and stakeholders
9. Knowledge of compliance requirements, medical ethics, and healthcare regulations
10.Ability to identify and mitigate fraud, waste, and abuse in claims

Qualifications
1. Bachelor's degree/Diploma in nursing or clinical medicine, or a related field.
2. Professional Nursing qualification KRCHN licensed by Nursing council of Kenya.
3. Relevant certifications in case management, healthcare management, or clinical specialties.

Relevant Experience
Minimum of two (2) years of relevant experience in a similar or equivalent role within a medical insurance environment, with demonstrated expertise in inpatient care coordination, insurance benefit administration, policy interpretation, and pre-authorization processes. Experience in provider engagement will be an added advantage.

If you are qualified and seeking an exciting new challenge, please apply via
Recruitment@jubileekenya.com quoting the Job Reference Number and
Position by 22nd September 2025.
Only shortlisted candidates will be contacted.