Job Purpose:

Lead care management and utilization review functions, aligning medical decisions with underwriting principles, supporting pre-authorizations, ensuring quality outcomes, cost efficiency, and client satisfaction.

Key Responsibilities:

• Ensure smooth patient journey in accessing care. Outpatient – quick turnaround on pre-authorizations and Inpatient smooth admission and discharge process
• Manage pre-authorization, discharge, case review, and claims adjudication
• Monitor healthcare provider performance; recommend panel adjustments
• Oversee call centre operations; ensure resolution and protocol compliance
• Maintain accurate patient records for traceability and audits
• Liaise with providers, insurers, clients, and internal teams for service coordination
• Train internal staff on claims, clinical data interpretation, and care protocols
• Implement cost management strategies including negotiations with insurers, hospitals, doctors and other stakeholders.
• Develop and update case management protocols; ensure industry compliance
• Evaluate and manage provider panel; negotiate terms and contracts
• Support underwriting with expert medical opinions on complex cases
• Audit high-cost/long-term cases; recommend treatment alternatives
• Contribute to client education with wellness guidelines and utilization reports

Qualifications:

• Degree in Nursing, Clinical Medicine, or related field
• Certification in Health Insurance or Case Management (preferred)
• Advanced training in Utilization Review or Managed Care

Experience:

• Minimum 5 years in care management or medical underwriting

Skills & Competencies:

• Clinical proficiency; diagnostic and treatment standards
• Analytical acumen; medical records and coverage impact analysis
• Insurance literacy; policy and medical coding knowledge
• Communication and collaboration with stakeholders
• Detail-oriented; document accuracy and compliance
• Team leadership and capacity-building
• Problem-solving mindset; service and claims resolution