Care Manager

Role Overview

This role sits at the point where health cover meets real medical need: you assess outpatient, optical, and dental preauthorization requests and decide whether each one aligns with the member's policy wording. You act as the bridge between members, brokers, and medical providers, making sure approvals, declines, and open questions are communicated quickly and clearly. You also share responsibility for the 24-hour emergency helpline, so your judgement shapes both how fast people access care and how well scheme costs are kept in check.

Key Responsibilities

• Review preauthorization requests for outpatient, optical, and dental services, issuing undertakings that match policy provisions precisely and applying the same rigour when a decline is the correct outcome.
• Meet agreed turnaround times on approvals and maintain a zero-error standard when capturing data and adjudicating benefits in the system.
• Request and review clinical evidence — medical reports, investigation results, and similar documentation — from providers in line with standard procedure.
• Keep clients, brokers, and providers promptly informed of claim decisions, outstanding requirements, and any concerns that arise.
• Cover the 24-hour emergency helpline, triaging calls and taking the necessary action outside normal working hours.
• Engage providers on cost matters including discounts, pre-agreed rates, packages, fixed-cost, and average-cost arrangements.
• Coordinate with the claims team to revisit earlier positions when new information changes the picture, with underwriting on scheme scope of cover, and with provider relations on panel issues and customer complaints.
• Resolve problems raised by members, brokers, and providers in a way that is legal, ethical, and consistent with policy principles, while supporting client presentations and member education on benefit utilisation and risk management.
• Contribute to departmental strategic initiatives and QA committee recommendations, uphold internal process compliance and IRA regulations, meet NPS targets on customer service indicators, and support colleagues so team deliverables are met within set timelines.

Requirements & Qualifications

• Bachelor's degree in nursing or clinical medicine.
• At least 2 years of case management experience or a closely related role.
• Demonstrated ability to manage admissions and discharges.
• Working knowledge of health benefits plan management and the ability to interpret policy wording accurately.
• Strong customer service orientation with a sense of responsibility and commitment to outcomes.
• Excellent communication skills and the ability to handle multiple tasks at once.
• Well-developed negotiation and decision-making skills, plus a collaborative team spirit.