Overall Responsibility:

Care Management, handling Inpatient preauthorizations, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns. Doing proper case management by doing physical visits and virtual follow up of all admitted members. Providing mentorship to the care managers in the team.

Key Responsibilities:

• Care Management – Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise, for declines, ensuring that the decisions are accurate and a correct interpretation of the policy
• Ensure appropriate Turnaround Time is adhered to in issuing approvals.
• Seeking medical clarifications including medical reports, copies of investigation reports
• Broker/customer relations by communicating all necessary admission claim decisions on a timely basis.
• Work with the claims team and coordinating on any information noted in the claims especially inpatient claims submitted in cases where further information provided changes the position undertaken previously on the claim.
• Reviewing medical pre-authorizations for compliance with applicable policy guidelines.
• Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is legal, ethical and consistent with the principles of the policy.
• Visiting/engaging admitted patients and ensuring they receive quality and cost-effective quality care
• Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost model
• Checking and confirming membership validity and benefits (from the scheme benefits file)
• Handling of coverage enquiries with brokers, providers, members etc.
• Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.
• Obtaining additional required information on claims from providers, brokers or clients
• Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
• Liaising with underwriting section on scope of cover for various schemes
• Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc
• Client presentations and member education on wise utilization & risk management
• Support the care management team to ensure all the deliverables are met within the given turnaround time

Skills and Competencies Required

• Health Benefits Plan Management
• Policy Interpretation
• Customer Service and Focus
• Ownership & commitment
• Team Spirit
• Excellent communication
• Ability to multi-task
• Strong negotiation and decision-making skills

Knowledge & Work Experience

• At least 3 years’ case management experience in a medical insurance environment, with at least 2 years as a care manager.
• Demonstrated knowledge of managing admissions and discharges in a busy insurance company
• Demonstrated experience in engaging service providers and doctors and negotiating cost
• Demonstrated experience in case management reports, physical visits, virtual follow up of admitted cases

Academic and Professional Qualifications required

• Bachelor’s degree in nursing or clinical medicine
• At least two-year’s experience in a care management role.