Case Management Officer

About the role

The Case Management Officer will act as the critical link between clinical care and the hospital’s financial operations. Reporting to the Assistant Claims Manager, the role ensures that patient care plans, utilization, and treatment protocols are monitored in real time while guaranteeing that all medical claims are accurately audited, coded, and verified before dispatch.

Key responsibilities

• Monitor active patient care, track length of stay, clinical necessity, and secure pre‑authorizations and limit extensions on scheme portals.
• Inform clinical teams and patients about policy exclusions, limits, and co‑pays to prevent billing disputes.
• Serve as the primary liaison between doctors, hospital staff, and corporate/insurance case managers to ensure fully coded billing clearance at discharge.
• Audit treatment patterns to curb over‑utilisation and ensure adherence to standard clinical protocols.
• Verify claims before processing, confirm diagnosis matches prescribed drugs and investigations, and highlight exclusions to reduce rejections.
• Sign on behalf of doctors when signatures are missing, complete claim forms, and work with the dispatch team to verify claims.
• Reconcile rejected invoices, monitor invoice returns, and take corrective action within a week of receipt.

Required profile

• Diploma in Clinical Medicine or equivalent from a recognised institution.
• Current practising certificate and membership with the relevant professional body.
• Minimum of 3 years’ experience in a busy hospital or insurance environment.
• Results‑driven, ethical and adaptable professional with a strong service and stakeholder focus.
• High integrity and sensitivity in handling confidential information.

Required skills

• ICD‑10 coding
• Medical claim auditing
• Utilisation review