Case Management Officer – Healthcare Claims

About the role

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

Key responsibilities

• Set admission parameters such as claim reserve, authorized cost and duration.
• Interact with clients and service providers to guarantee care 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 claims are processed within stipulated timeframes.
• Follow the approved Delegated Authority Matrix.
• Perform any other duties as assigned.

Required profile

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

Required skills