Job Ref. No: JHIL089

Role Purpose

The primary purpose of the Case Manager is to execute comprehensive case management strategies that improve member health, enhance satisfaction, and effectively manage healthcare costs. This role requires strategic thinking, clinical expertise, and a deep understanding of insurance regulations.

Main Responsibilities

Strategy

• Execute robust case management strategies aligned with the organization’s mission and objectives.
• Identify opportunities for innovative interventions, process enhancements, and cost-effective healthcare solutions.
• Stay updated with industry trends, healthcare practices, and regulatory changes to inform strategic decision-making.
• Monitor, analyse, and report on case management outcomes to drive continuous improvement.

Operational

• Evaluate complex cases to determine appropriate care plans, considering medical necessity, cost-effectiveness, and optimal outcomes for insured members.
• Collaborate with healthcare providers, specialists, and support services to coordinate comprehensive care for insured members, ensuring continuity and effectiveness.
• Review and approve care/treatment plans, ensuring they align with medical guidelines, member needs, and insurance coverage.
• Engage with insured members to explain care options, address concerns, and provide ongoing support throughout their healthcare journey.
• Maintain relationships with healthcare providers, ensuring timely communication, accurate information exchange, and high-quality care delivery.
• Monitor and manage the utilization of medical services to ensure appropriate and cost-effective care while maintaining quality standards.
• Conduct clinical reviews of cases, assess treatment efficacy, ensure adherence to best practices, and recommend adjustments when needed.
• Maintain comprehensive and accurate case records, including assessments, care plans, progress notes, and outcomes.
• Address complex case management issues, collaborating with internal teams, providers, and stakeholders to find effective solutions.
• Work closely with cross-functional teams, including claims, legal, compliance, and customer service, to ensure seamless coordination and communication.
• Ensure all case management activities, from assessment to follow-up, are carried out within established timeframes to provide timely care.
• Handle urgent cases promptly, collaborating with providers to ensure timely and appropriate interventions.
• Generate regular reports on case management metrics, outcomes, and performance to present to senior management and stakeholders.

Corporate Governance

• Ensure strict compliance with healthcare regulations, insurance guidelines, and ethical standards within the Case Management function.
• Collaborate with legal and compliance teams to address complex regulatory and legal issues related to case management.
• Contribute to executive-level reporting and strategic discussions regarding case management initiatives.
• Ensure all case management activities adhere to healthcare regulations, insurance policies, and ethical standards.

Requirements

Key Competencies

• Develop and refine case management protocols and guidelines to ensure consistent and high-quality care coordination.
• Manage utilization of medical services to achieve cost containment goals while maintaining healthcare quality.
• Coordinate comprehensive care plans to optimize health outcomes, member satisfaction, and long-term wellness.
• Foster effective communication and collaboration among internal teams and external partners.

Qualifications

• Bachelor’s degree in nursing or clinical medicine, or a related field.
• Relevant certifications in case management, healthcare management, or clinical specialties.

Relevant Experience

• Minimum of 2 years of relevant working experience in a similar or equivalent role