Care Manager - First Assurance

Job Summary

The Case Manager proactively collaborates with health insurance clients, intermediaries, medical service providers, and internal teams to facilitate access to quality, safe, timely, effective, and cost-efficient healthcare services. This role requires staying continuously updated on industry innovations, challenges, and emerging trends to deliver top‑notch service. Success is directly measured through critical performance metrics, including high customer satisfaction, effective cost containment, strict adherence to medical protocols, rapid turnaround times (TATs), and full compliance with all company policies, legal guidelines, and regulatory requirements.

Key Responsibilities

Case Adjudication & Authorization

• Conduct due diligence and issue undertakings in line with policy provisions. For declines or partial approvals, ensure accurate decisions and correct policy interpretation.
• Review patient history and records to determine the cause of disease and assess whether treatment correlates with the diagnosis and applicable benefits.
• Pre‑authorize admissions, discharges, scheduled and emergency medical cases, issuing timely responses per policy benefits and company guidelines.
• Set appropriate parameters for each admission (claim reserve, initial authorized cost, and duration) and ensure their compliance.
• Vet and confirm validity of services provided by the provider in relation to benefits covered, treatment given, adherence to panel rules, and treatment costs.
• Ensure zero‑error rate in benefit adjudication and accurate capture of information in the system.

Patient & Provider Interaction

• Conduct admitted patient visits and daily follow‑ups, ensuring quality and cost‑effective care.
• Review admitted patients’ treatment plans daily, monitor improvements and bill escalation, guide coverage, inform intermediaries, and coordinate care.
• Negotiate with providers, doctors, and hospitals on costs, tariffs, discounts, pre‑agreed rates, packages, and fixed‑cost models.
• Interact with clients, brokers, and clinicians to resolve problems in a timely, ethical, and compliant manner.
• Follow through on escalated customer and provider queries and complaints, advise on outcomes and medical product details.
• Advise members on wise utilization of benefits, recommending cost‑effective facilities and cheaper options (e.g., maternity packages, chronic management).

Collaboration & Reporting

• Collaborate with Brokers/Agents/Corporate HR and Customer Relations, communicating admission claim decisions on a timely basis.
• Work closely with cross‑functional teams (provider relations, call center, claims, underwriting, audit) to address customer needs and provide comprehensive solutions.
• Send daily admissions reports to clients, Brokers/Agents/company HR managers.
• Prepare and compile section reports on daily, weekly, and monthly basis and forward to management.

Process Improvement & Innovation

• Identify areas for process enhancement, suggest improvements, and implement innovative solutions to streamline operations.
• Generate, recommend, and implement preventive care programs through health talks, wellness initiatives, and the Chronic Disease Management Program (CDMP).
• Send weekly and monthly reports on admissions, exceptional claims, long‑stay cases, savings, and other metrics.

Compliance & Confidentiality

• Observe confidentiality of client information and comply with the Data Protection Act.
• Adhere to appropriate Turnaround Times when issuing approvals, letters of undertaking, and correspondence.
• Perform all other tasks as assigned by the line manager.

Knowledge Management

• Improve technical knowledge through self‑learning or training, including mandatory Continuous Professional Education requirements.
• Share knowledge with colleagues and peers in the business.
• Develop and enhance learning through seeking coaching, training, and continual feedback.

Relationship Management

Develop and maintain strong relationships with colleagues and clients, including Brokers/Agents and company Human Resource managers.

Qualifications & Competencies

Education & Experience

• Education: Bachelor’s Degree or Diploma in Nursing (KRCHN), Clinical Medicine, Health Management, or a related field.
• Experience: Minimum 2 years of clinical experience and 1 year of case management experience.
• Licensed by the relevant statutory regulator in the respective medical field.
• Member of a relevant professional medical association in good standing.

Skills & Knowledge

• Technical Skills: Proficiency in Microsoft Office Suite.
• Soft Skills: Excellent communication, empathy, negotiation, problem‑solving abilities, adaptability, and a customer‑centric approach.
• Industry Knowledge: Understanding of insurance policies, regulations, compliance, and standards.