Care Manager – Health Insurance Services

About the role

The Care Manager will work closely with health‑insurance clients, brokers, medical service providers and internal teams to ensure members receive safe, timely and cost‑effective healthcare. The role requires staying up‑to‑date with industry trends and delivering service that meets strict performance and compliance standards.

Key responsibilities

• Review patient histories and medical records to verify diagnosis, treatment relevance and benefit eligibility.
• Pre‑authorize admissions, discharges, scheduled and emergency cases, setting claim reserves, authorized costs and duration.
• Issue approvals, letters of undertaking and correspondence within defined turnaround times.
• Conduct daily follow‑ups with admitted patients to monitor quality and cost‑effectiveness of care.
• Communicate admission decisions promptly to brokers, agents, corporate clients and customer‑relations teams.
• Negotiate rates, tariffs and discounts with providers, doctors and hospitals while ensuring adherence to panel rules.
• Validate service provision against policy benefits and capture accurate information in the claims system with zero‑error adjudication.
• Collaborate with cross‑functional departments to resolve issues in line with legal and regulatory requirements.

Required profile

• Strong understanding of health‑insurance policies, medical protocols and benefit structures.
• Ability to analyse clinical documentation and make accurate benefit determinations.
• Excellent communication skills for interaction with clients, brokers, clinicians and internal stakeholders.
• High attention to detail and commitment to zero‑error claim processing.
• Proactive approach to staying informed about industry innovations and regulatory changes.

Required skills