Case Management Officer

Role Overview

This position sits within the clinical operations team, reporting directly to the Manager Clinicals, and is responsible for steering the full policy cycle for medical admissions—starting with pre-authorization and continuing through active case management. The core purpose is to deliver quality, cost-effective care by setting appropriate financial and clinical parameters for each case, reviewing medical evidence, and intervening when treatment plans fall outside policy guidelines. Working closely with clients, healthcare providers, and underwriters, the role ensures that scheme members receive timely, guideline-compliant care while the organization controls its claims exposure.

Key Responsibilities

• Set and manage the clinical and financial parameters for each admission, including claim reserves, initial authorized treatment costs, and length of stay.
• Act as the primary liaison between clients and service providers to confirm that all planned care falls within the scheme’s policy framework.
• Review medical reports and submitted claims to verify alignment with set guidelines, flagging discrepancies and requesting additional information where needed.
• Collaborate with underwriters to clarify the scope of cover across different schemes, ensuring consistent application of policy terms.
• Monitor the 24-hour call centre to guarantee that scheme members receive continuous, round-the-clock support and appropriate referrals.
• Challenge prescriptions that indicate poly-pharmacy, proposing safer, more cost-effective alternatives in consultation with prescribers.
• Encourage generic substitution wherever clinically appropriate, helping reduce the organization’s overall pharmaceutical spend without compromising care quality.
• Prepare periodic management reports on medical claims activity, outcomes, and trends, and ensure all claims are finalized within agreed service timelines.

Requirements & Qualifications

• A Diploma or Degree in Nursing, a Diploma in Clinical Medicine, or a Diploma in Pharmacy.
• 3–4 years of hands-on experience in case management, preferably within a medical insurance or managed care environment.
• Demonstrated understanding of insurance concepts, including policy terms, claim cycles, and reimbursement principles.
• Professional certifications such as FLMI, ACII, or IIK will be considered an added advantage.
• Strong analytical and decision-making skills to assess medical necessity and balance quality of care with cost control.
• Excellent written and verbal communication skills for interacting with medical professionals, clients, and internal stakeholders.