Job Purpose:
Lead care management and utilization review functions,
aligning medical decisions with underwriting principles, supporting
pre-authorizations, ensuring quality outcomes, cost efficiency, and client
satisfaction.
Key Responsibilities:
- Ensure
smooth patient journey in accessing care. Outpatient – quick turnaround on
pre-authorizations and Inpatient smooth admission and discharge process
- Manage
pre-authorization, discharge, case review, and claims adjudication
- Monitor
healthcare provider performance; recommend panel adjustments
- Oversee
call centre operations; ensure resolution and protocol compliance
- Maintain
accurate patient records for traceability and audits
- Liaise
with providers, insurers, clients, and internal teams for service
coordination
- Train
internal staff on claims, clinical data interpretation, and care protocols
- Implement
cost management strategies including negotiations with insurers,
hospitals, doctors and other stakeholders.
- Develop
and update case management protocols; ensure industry compliance
- Evaluate
and manage provider panel; negotiate terms and contracts
- Support
underwriting with expert medical opinions on complex cases
- Audit
high-cost/long-term cases; recommend treatment alternatives
- Contribute
to client education with wellness guidelines and utilization reports
Qualifications:
- Degree
in Nursing, Clinical Medicine, or related field
- Certification
in Health Insurance or Case Management (preferred)
- Advanced
training in Utilization Review or Managed Care
Experience:
- Minimum
5 years in care management or medical underwriting
Skills & Competencies:
- Clinical
proficiency; diagnostic and treatment standards
- Analytical
acumen; medical records and coverage impact analysis
- Insurance
literacy; policy and medical coding knowledge
- Communication
and collaboration with stakeholders
- Detail-oriented;
document accuracy and compliance
- Team
leadership and capacity-building
- Problem-solving
mindset; service and claims resolution
More Information
- Experience
Level Manager
- Total
Years Experience 5-10