Job Ref. No: JHIL128
Role Purpose
The primary purpose of the Case Manager, Active Case Management is to monitor and manage 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
Strategy
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
Operational
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.
Regulatory Compliance
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.
Leadership & Culture
Fostering a corporate culture that promotes ethical practices and good corporate citizenship while maintaining a conducive work environment.
Collaborate with cross-functional teams to develop initiatives that promote a positive and inclusive company culture.
Individualized Development Planning: Create personalized development plans that align with your career aspirations and the organization's objectives.
Compliance
Legal Adherence: Stay well-informed about relevant laws and regulations, including Anti-Money Laundering (AML) and Counter Financing of Terrorism (CFT) laws, Data Protection laws, and Insurance law. Ensure compliance with these legal requirements in all operational aspects.
Policy Alignment: Understand and adhere to internal company policies, processes, and procedures. Report any instances of non-compliance promptly to management and the designated compliance officer.
Risk Mitigation: Take proactive measures to identify and mitigate compliance risks within your role and department. Participate actively in training programs and awareness sessions to stay updated on compliance requirements and best practices.
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.
Educational Background
Bachelor's degree in nursing or clinical medicine, or a related field.
Relevant certifications in case management, healthcare management, or clinical specialties.
Relevant Experience
Two (2) years relevant working experience
