Job purpose:
To oversee and coordinate all pre-authorization, admission, discharge, and care coordination activities, ensuring quality patient care while managing medical costs and provider relationships effectively.
Key responsibilities:
-
Oversee medical case management and pre-authorizations.
-
Ensure timely and appropriate approvals for inpatient and outpatient services.
-
Collaborate with hospitals, TPAs, and providers to ensure quality care delivery.
-
Monitor and track high-cost cases, chronic illnesses, and frequent claimants.
-
Offer clinical guidance to underwriters and claims analysts on complex cases.
-
Train and mentor staff and ensure process adherence.
-
Maintain and update provider tariff lists and treatment protocols.
-
Support fraud detection and provider performance reviews.
-
Stay updated on industry trends, emerging risks, regulatory changes, and new technologies that could affect underwriting practices.
-
Deliver on performance requirements as defined in the departments’ strategy map, balanced scorecard and Personal Scorecard.
- Perform any other duties as may be assigned from time to time
Knowledge, experience and qualifications required:
-
Bachelor’s Degree or Diploma in Nursing, Clinical Medicine, or related health field.
-
2-4 years’ experience in medical case management in the insurance sector.
-
Strong clinical knowledge and experience managing medical claims or provider relations.
-
Excellent communication and decision-making skills.
-
Ability to work under pressure and coordinate with multiple stakeholders.
-
Experience in customer, market and competitor understanding.
- Knowledge of Insurance regulatory requirements.