Case Manager - Health Insurance

About the role

The Case Manager coordinates care for enrollees so that they receive the right healthcare services in a timely and cost-effective way. Working with healthcare providers, enrollees and internal teams, the role covers treatment plans, hospital admissions and outpatient care, and requires strong interpersonal skills and the ability to track several cases at once.

Key responsibilities

• Act as the main point of contact for enrollees, coordinating appointments, referrals and adherence to care plans
• Work with providers to deliver inpatient and outpatient care, and track enrollee progress
• Facilitate referrals to specialists or hospitals, with proper documentation and pre-authorisation
• Work with the provider relations team so that providers meet quality standards and are accessible
• Inform enrollees of their rights and benefits and guide them through the referral process
• Review and monitor cases regularly, keeping accurate records of medical history, treatments and follow-ups
• Ensure care follows HMO guidelines and is medically necessary
• Protect confidential information, comply with data protection laws and report suspected breaches
• Take part in departmental knowledge sharing and support the Managing Director and Vice Chairman as needed

Required profile

• Bachelor's degree in Nursing, Healthcare Administration or a related field
• At least 4 years of experience in case management or healthcare coordination, preferably in an HMO or health insurance setting

Required skills

• Managing medical cases and developing care plans based on enrollee needs
• Excellent communication with providers, enrollees and families
• Solid understanding of the healthcare system, insurance processes and the HMO model