Case Management Officer

About the role

The Case Management Officer reports to the Manager Clinicals and is responsible for overseeing the policy cycle through pre‑authorization and case management. The role ensures that members receive quality, cost‑effective care while adhering to policy guidelines.

Key responsibilities

• Set appropriate parameters for each admission, including claim reserve, authorized cost and duration.
• Interact with clients and service providers to confirm care delivery within policy limits.
• Review medical reports and claims for compliance with established guidelines.
• Liaise with underwriters to define scope of cover for various schemes.
• Provide 24‑hour support to medical scheme members via a call centre.
• Discourage poly‑pharmacy by challenging prescriptions and suggesting alternatives.
• Promote generic substitution to reduce pharmaceutical expenditure.
• Prepare periodic management reports on medical claims.
• Ensure timely processing of claims according to stipulated deadlines.

Required profile

• Diploma or degree in Nursing, Clinical Medicine, or Pharmacy.
• Understanding of insurance concepts.
• Professional qualifications such as FLMI, ACII or IIK are advantageous.
• 3–4 years of experience in case management.

Required skills