Terms of Reference

Posted: 2026-06-18 21:00:00  Deadline: Not Specified   Full-time   Salary: Confidential

The Case Management Officer is responsible for controlling and managing medical insurance cases to ensure quality, cost effective care, excellent client service, and efficient processing and payment of Britam Microinsurance claims. The role involves coordinating with clients, healthcare providers, and internal teams to ensure claims are managed in accordance with policy guidelines and regulatory requirements.

Key Responsibilities

Set appropriate admission parameters including claim reserves, authorized costs, and duration of care.
Interact with clients and healthcare service providers to ensure treatment is provided within policy guidelines.
Review medical reports and claims to ensure compliance with established procedures and guidelines.
Liaise with underwriters to clarify the scope of cover for different medical schemes.
Ensure medical scheme members receive timely assistance through the 24 hour call centre.
Discourage unnecessary poly pharmacy by reviewing prescriptions and recommending suitable alternatives.
Promote the use of generic medicines where appropriate to help reduce pharmaceutical costs.
Review claim documents and supporting requirements submitted by providers and clients.
Verify that claims are complete and meet all insurance documentation requirements.
Build and maintain effective relationships with clients, intermediaries, and healthcare service providers.
Verify and audit outpatient and inpatient claims to ensure compliance and minimize risk.
Advise claimants on insurance coverage and claims related matters.
Respond to internal and external enquiries regarding claims processes, service providers, and documentation requirements.
Record all claims transactions accurately and maintain up to date records.
Prepare claims registers for claims meetings and update claims reports.
Track and follow up on outstanding claim documentation.
Perform duties within the approved Delegated Authority Matrix.
Perform any other duties assigned from time to time.

Qualifications

Professional Nursing qualification with KRCHN certification licensed by the Nursing Council of Kenya.
Two to four years of experience in case management and claims processing.
Knowledge of insurance regulatory requirements.
Good understanding of insurance products.

Key Competencies

Strong analytical and medical claims assessment skills.
Excellent communication and interpersonal skills.
Strong attention to detail and accuracy.
Ability to build and maintain relationships with clients and healthcare providers.
Good organizational and record management skills.

Job Details

Employer: Britam.
Position: Case Management Officer.
Job Type: Permanent.
Contract Type: Full Time.
Location: Nairobi, Kenya.
Number of Openings: 1.

Application Process

Interested and qualified candidates should submit their applications through the official Britam careers portal. This vacancy was posted on 18th June 2026 and remains open until filled.

Official Job Description: Case Management Officer