Job Summary

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.

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.

Provides leadership and mentorship to Care Management and Provider Partnerships teams to drive quality outcomes, efficiency, and sustainable growth.

Job Description

Strategic Leadership & Provider Partnerships

• Develop and implement the overall strategic plan for the Care/Case Management and Provider Partnerships functions, aligned with the company’s broader medical business objectives.
• Design and execute provider network strategies that ensure quality, accessibility, cost-efficiency, and geographic coverage.
• Lead strategic engagement with hospitals, specialists, and healthcare facilities to establish long-term, mutually beneficial partnerships.
• Drive negotiation and contracting of pre-agreed rates, discounts, packages, and fixed-cost models with providers.
• Identify and implement value-based care initiatives and innovative reimbursement models.
• Monitor industry trends, healthcare practices, regulatory changes, and emerging provider models to inform strategic decisions.
• Analyze care and provider performance data to identify cost drivers, utilization trends, and partnership optimization opportunities.
• Develop risk mitigation strategies based on claims trends and provider performance.
• Prepare periodic executive reports on case management outcomes, provider performance, cost containment initiatives, and network adequacy.

Operations Management – Case Management

• Lead day-to-day case management operations to ensure efficient, timely, and high-quality service delivery to clients.
• Oversee clinical case reviews to confirm medical necessity, policy alignment, and appropriate treatment pathways.
• Establish and monitor admission controls including claim reserves, authorized costs, and length of stay to ensure compliance and cost containment.
• Drive healthcare quality and cost optimization through utilization management, provider collaboration, and proactive bill negotiation.
• Manage complex and active cases, including emergency evacuations, referrals, and local/international transfers.
• Ensure effective stakeholder coordination with Provider Relations, contact center, intermediaries, and scheme administrators for seamless communication and service continuity.
• Oversee documentation, escalations, and complaint resolution to maintain service excellence, transparency, and regulatory compliance

Operations Management- Provider Partnerships

• Lead provider onboarding and credentialing oversight, ensuring robust due diligence and continuous performance evaluation.
• Drive provider performance management through scorecards tracking quality, cost efficiency, turnaround times, member satisfaction, and SLA compliance.
• Strengthen provider partnerships through regular engagement meetings, facility visits, and collaborative initiatives to improve patient outcomes and reduce avoidable admissions.
• Ensure contract and tariff compliance, including oversight of dispute resolution and complex claim negotiations.
• Optimize the provider network by identifying expansion or rationalization opportunities based on utilization trends and business needs.

Accountability: People Management

• Lead, mentor and develop a high performing team of medical insurance professionals.
• Foster a positive and collaborative work environment that encourages innovation and teamwork
• Together 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.
• Review workforce and recruitment plans for the area and re-allocate resources where required.
• Entrenching performance-based appraisal of department staff in line with their set KPI 

Accountability: Risk Management

• Identify and mitigate operational, financial, clinical, and reputational risks within care management and provider partnerships.
• Ensure strict adherence to healthcare regulations, insurance guidelines, and ethical standards.
• Collaborate with Legal and Compliance teams on complex cases and regulatory matters.
• Implement internal controls to prevent fraud, waste, and abuse.
• Drive a culture of proactive compliance and ethical provider engagement.
• Ensure all contracting and provider engagement activities meet regulatory and governance standards.

• Any other duties that fall under the responsibility of the role at First Assurance Company.

Education and Qualifications Required (Essential)

• Bachelor’s degree in nursing, Clinical Medicine, or related medical field (Diploma holders with strong experience may be considered).
• A diploma in insurance will be an added advantage. 
• Minimum of 7 years’ experience in clinical operations within the health insurance sector, including at least 3 years in a supervisory or leadership role.
• Relevant professional qualification.
• Must be a member of a professional body in good standing.