Job Summary

Care Management, handling Inpatient preauthorization’s, and communicating with providers, clients, and intermediaries on a timely basis for any undertakings, rejections, or relevant concerns. Monitoring and managing 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. Supervising and providing mentorship to the care managers in the team.

Job Description

Accountability: Strategic:

• Develop and implement the overall strategic plan for the Care/ Case Management Sections of the Medical business, aligned with the company’s overall business objectives.
• Ensure Formulation and implementation of policies and strategies for effective and efficient case management.
• 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.
• Engaging providers on matters cost, discounts, pre agreed rates, packages/fixed cost model.
• Monitor, analyse, and report on case management outcomes to drive continuous improvement.

Accountability: Operations Management:

• Oversee the day-to-day case management, ensuring efficient and effective service delivery of services to clients.
• Visiting/engaging admitted patients and ensuring they receive quality and cost-effective quality care.
• Ensure appropriate turnaround time is adhered to in issuing approvals.
• Reviewing medical pre authorizations for compliance with applicable policy guidelines.
• Maintain detailed and accurate records of assessments, care plans, and interactions with policyholders and healthcare providers.
• Monitor the quality of healthcare services provided to policyholders.
• Identify opportunities for improvement and work with healthcare providers to enhance care quality.
• Work to manage healthcare costs by ensuring that care is appropriate, cost-effective, and aligned with policy coverage.
• Evaluate active insurance cases to understand policy coverage, claim status, and the specific needs and concerns of policyholders.
• Develop and maintain strong relationships with healthcare service providers, negotiating favourable rates and service agreements.
• Liaising with provider relations section on matters pertaining to provider panel, customer complaints.
• Support the care management team to ensure all the deliverables are met within the given turnaround time

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.
• Recruit, hire and onboard talented individuals to support the growth of the medical insurance business
• Review workforce and recruitment plan for the area and re-allocate resources where required.

Accountability: Risk Management:

• Identify and mitigate potential risks associated with the medical insurance business, including operational, financial, and reputational risks.
• Ensure compliance with all relevant regulatory requirements.
• Ensure strict compliance with healthcare regulations, insurance guidelines, and ethical standards within the Care/Case Management function.
• Collaborate with legal and compliance teams to address complex regulatory and legal issues related to case management.
• Ensure all case management activities adhere to healthcare regulations, insurance policies, and ethical standards.
• Drive a culture of proactive compliance in the function.
• Any other duties that fall under the responsibility of the Case/Care Manager at First Assurance Company.

Education and Qualifications Required (Essential):

• Bachelor’s degree in nursing/clinical medicine or a diploma in nursing/clinical medicine with a diploma in insurance.
• A diploma in insurance will be an added advantage.
• Relevant professional qualification.
• Must be a member of a professional body in good standing.