Job Ref. No: JHIL163

Role Purpose

The Case Manager will be responsible for 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.

Key Responsibilities

• Execute robust case management strategies aligned with the organization's mission and objectives.
• Identify opportunities for innovative interventions, process enhancements, and costeffective healthcare solutions.
• Stay updated with industry trends, healthcare practices, and regulatory changes to inform strategic decision-making.
• Monitor, analyse, and report on case management outcomes to drive continuous improvement.
• Advocate on behalf of policyholders to ensure they receive necessary and appropriate healthcare services.
• Address any barriers to care, such as communication issues or insurance-related concerns.
• 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.
• Negotiation and Settlement; Engage in negotiation with medical providers to achieve equitable settlements of hospital bills when required.
• Ensure strict compliance with healthcare regulations, insurance guidelines, and ethical standards within the 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.

Key Skills and Competencies

• Exceptional leadership and team management skills.
• Strong analytical and critical-thinking abilities.
• Effective communication and interpersonal skills.
• Strategic vision and decision-making prowess.
• Thorough understanding of healthcare regulations and insurance practices.
• Clinical knowledge and medical expertise.

Academic & Professional Qualifications

• Bachelor's degree in nursing or clinical medicine, or a related field.
• Relevant certifications in case management, healthcare management, or clinical specialties.

Relevant Experience

• A minimum of two 2 years relevant working experience. Ideal candidates should possess a strong understanding of Medical Insurance.