Job Summary<\/p>\n
Lead and oversee Care Management operations, including inpatient preauthorization’s, utilization management, and clinical case reviews, ensuring high-quality, timely, and cost-effective healthcare delivery.<\/p>\n
Develop and manage strategic provider partnerships by optimizing the provider network, negotiating cost structures, driving value-based care initiatives, and ensuring sustainable cost control, compliance, operational excellence, and strong team leadership.<\/p>\n
Provides leadership and mentorship to Care Management and Provider Partnerships teams to drive quality outcomes, efficiency, and sustainable growth.<\/p>\n
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Job Description<\/p>\n
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Strategic Leadership & Provider Partnerships<\/p>\n
\tDevelop and implement the overall strategic plan for the Care\/Case Management and Provider Partnerships functions, aligned with the company\u2019s broader medical business objectives.
\n\tDesign and execute provider network strategies that ensure quality, accessibility, cost-efficiency, and geographic coverage.
\n\tLead strategic engagement with hospitals, specialists, and healthcare facilities to establish long-term, mutually beneficial partnerships.
\n\tDrive negotiation and contracting of pre-agreed rates, discounts, packages, and fixed-cost models with providers.
\n\tIdentify and implement value-based care initiatives and innovative reimbursement models.
\n\tMonitor industry trends, healthcare practices, regulatory changes, and emerging provider models to inform strategic decisions.
\n\tAnalyze care and provider performance data to identify cost drivers, utilization trends, and partnership optimization opportunities.
\n\tDevelop risk mitigation strategies based on claims trends and provider performance.
\n\tPrepare periodic executive reports on case management outcomes, provider performance, cost containment initiatives, and network adequacy.<\/p>\n
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Operations Management – Case Management<\/p>\n
\tLead day-to-day case management operations to ensure efficient, timely, and high-quality service delivery to clients.
\n\tOversee clinical case reviews to confirm medical necessity, policy alignment, and appropriate treatment pathways.
\n\tEstablish and monitor admission controls including claim reserves, authorized costs, and length of stay to ensure compliance and cost containment.
\n\tDrive healthcare quality and cost optimization through utilization management, provider collaboration, and proactive bill negotiation.
\n\tManage complex and active cases, including emergency evacuations, referrals, and local\/international transfers.
\n\tEnsure effective stakeholder coordination with Provider Relations, contact center, intermediaries, and scheme administrators for seamless communication and service continuity.
\n\tOversee documentation, escalations, and complaint resolution to maintain service excellence, transparency, and regulatory compliance<\/p>\n
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Operations Management- Provider Partnerships<\/p>\n
\tLead provider onboarding and credentialing oversight, ensuring robust due diligence and continuous performance evaluation.
\n\tDrive provider performance management through scorecards tracking quality, cost efficiency, turnaround times, member satisfaction, and SLA compliance.
\n\tStrengthen provider partnerships through regular engagement meetings, facility visits, and collaborative initiatives to improve patient outcomes and reduce avoidable admissions.
\n\tEnsure contract and tariff compliance, including oversight of dispute resolution and complex claim negotiations.
\n\tOptimize the provider network by identifying expansion or rationalization opportunities based on utilization trends and business needs.<\/p>\n
Accountability: People Management<\/p>\n
\tLead, mentor and develop a high performing team of medical insurance professionals.
\n\tFoster a positive and collaborative work environment that encourages innovation and teamwork
\n\tTogether with the Human Capital Team, determine the people management strategy for the area with a focus on talent management, development, resourcing and retention. Communicate the strategy to managers in the area.
\n\tReview workforce and recruitment plans for the area and re-allocate resources where required.
\n\tEntrenching performance-based appraisal of department staff in line with their set KPI\u00a0<\/p>\n
Accountability: Risk Management<\/p>\n
\tIdentify and mitigate operational, financial, clinical, and reputational risks within care management and provider partnerships.
\n\tEnsure strict adherence to healthcare regulations, insurance guidelines, and ethical standards.
\n\tCollaborate with Legal and Compliance teams on complex cases and regulatory matters.
\n\tImplement internal controls to prevent fraud, waste, and abuse.
\n\tDrive a culture of proactive compliance and ethical provider engagement.
\n\tEnsure all contracting and provider engagement activities meet regulatory and governance standards.
\n\tAny other duties that fall under the responsibility of the role at First Assurance Company.<\/p>\n
Education and Qualifications Required (Essential)<\/p>\n
\tBachelor\u2019s degree in nursing, Clinical Medicine, or related medical field (Diploma holders with strong experience may be considered).
\n\tA diploma in insurance will be an added advantage.\u00a0
\n\tMinimum of 7 years\u2019 experience in clinical operations within the health insurance sector, including at least 3 years in a supervisory or leadership role.
\n\tRelevant professional qualification.
\n\tMust be a member of a professional body in good standing.<\/p>\n
Apply Through:<\/p>\n
absa.wd3.myworkdayjobs.com<\/p>\n","protected":false},"author":2,"featured_media":0,"template":"","meta":{"_promoted":"","_job_location":"","_application":"http:\/\/absa.wd3.myworkdayjobs.com","_company_name":"Absa Bank Limited","_company_website":"http:\/\/www.absa.co.za","_company_tagline":"Absa Bank Limited (Absa) is a wholly owned subsidiary of Barclays Africa Group Limited. Absa offers personal and business banking, credit cards, corporate and investment banking, wealth and investment management as well as bancassurance. Barclays Africa Group Limited is 62.3% owned by Barclays Ba... read morenk PLC and is listed on the JSE Limited. The Group is one of Africa\u2019s major financial services providers offering personal and business banking, credit cards, corporate and investment banking, wealth and investment management as well as bancassurance. The Group was formed through combining Absa Group Limited and Barclays\u2019 African operations on 31 July 2013. Reflecting the enlarged group\u2019s pan-African focus, the Group's name changed from Absa Group Limited, to Barclays Africa Group Limited on 2 August 2013. Registered head offices are in South Africa and the Group has majority stakes in banks in Botswana, Ghana,Kenya, Mauritius, Mozambique, Seychelles, South Africa, Tanzania (Barclays Bank Tanzania and National Bank of Commerce), Uganda and Zambia. The Group has representative offices in Namibia and Nigeria, as well as bancassurance operations in Botswana, Mozambique, South Africa and Zambia. Barclays Bank Kenya and Barclays Bank Botswana continue to be listed on their respective stock exchanges.Barclays Bank PLC has operations in Egypt and Zimbabwe, which are part of the African business and continue to be run by Barclays Africa Group\u2019s management","_company_twitter":"","_company_video":"","_filled":0,"_featured":0,"_remote_position":0,"_job_salary":"","_job_salary_currency":"","_job_salary_unit":""},"job_listing_region":[692],"job-categories":[693,734,714],"job-types":[687],"class_list":{"0":"post-91483","1":"job_listing","2":"type-job_listing","3":"status-publish","4":"hentry","5":"job_listing_region-nairobi","7":"job-type-full-time"},"jetpack_sharing_enabled":true,"_links":{"self":[{"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/job-listings\/91483","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/job-listings"}],"about":[{"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/types\/job_listing"}],"author":[{"embeddable":true,"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/users\/2"}],"wp:attachment":[{"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/media?parent=91483"}],"wp:term":[{"taxonomy":"job_listing_region","embeddable":true,"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/job_listing_region?post=91483"},{"taxonomy":"job_listing_category","embeddable":true,"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/job-categories?post=91483"},{"taxonomy":"job_listing_type","embeddable":true,"href":"https:\/\/jobs.dataaxisnode.com\/kenya\/wp-json\/wp\/v2\/job-types?post=91483"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}