Case Management Officer 

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.