Case Management Officer

Role Overview

Under the supervision of the Manager Clinicals, the Case Management Officer is tasked with overseeing the insurance policy life cycle by managing case approvals and ensuring the delivery of high-quality, cost-efficient care.

Primary Responsibilities

• Establish suitable parameters for patient admissions, including claim reserves, initial approval costs, and duration of care.
• Engage with clients and healthcare providers to guarantee care aligns with policy provisions.
• Assess medical documents and claims to verify adherence to established guidelines.
• Coordinate with underwriters concerning coverage specifics for diverse insurance schemes.
• Supervise continuous member care support, collaborating with a 24-hour call center to provide round-the-clock assistance.
• Address concerns related to poly-pharmacy by critically evaluating prescriptions and recommending cost-effective alternatives.
• Promote the substitution of brand medications with generics when appropriate to help reduce pharmaceutical expenses.
• Operate within the boundaries set by the approved Delegated Authority Matrix.
• Compile and deliver periodic reports on medical claims to management.
• Ensure timely processing of claims within specified deadlines.
• Carry out additional tasks as delegated.

Qualifications and Experience

• Possess a Diploma or Degree in Nursing, Clinical Medicine, or Pharmacy.
• Have a sound understanding of insurance principles and practices.
• Professional certifications such as FLMI, ACII, or IIK are considered advantageous.
• Bring 3 to 4 years of experience working in case management.