Case Management Officer overseeing patient care coordination, discharge planning, and healthcare utilization, requiring a Diploma in Clinical Medicine or equivalent and 3+ years clinical case management experience in a hospital setting.
Job Summary
Reporting to the Assistant Claims Manager the successful candidate will proactively oversee clinical care plans, utilization, and treatment protocols during active patient care while ensuring all medical claims are accurately audited, ICD-10 coded, and verified prior to dispatch.
He/She will be a vital bridge between clinical care and hospital financial operations—liaising with corporate/insurance clients, attending physicians, and internal billing teams to resolve clinical queries, clear discharge documentation, and establish strict controls that minimize claims rejections and revenue loss in line with the institution’s finance policy.
Key Responsibilities
Care
Management
- Active
Care & Authorization Oversight: Monitors patient care in real
time—tracking length of stay, clinical necessity, and treatment plans
while securing pre-authorizations and limit extensions on scheme portals
before charges accumulate.
- Proactive
Financial & Scheme Alignment: Inform clinical teams and patients early
on policy exclusions, limits, and co-pays to set clear expectations and
prevent billing disputes at discharge.
- Liaison
& Care Transition: Acts as the primary clinical link between attending
doctors, hospital staff, and corporate/insurance case managers. Ensures
smooth, fully coded billing clearance at discharge.
- Utilization
& Quality Assurance: Audits treatment patterns to curb
over-utilization (unnecessary drugs or duplicate tests) and ensures care
adheres to standard clinical protocols.
Verification
of claims before processing for dispatch to corporate clients.
- Check
if diagnosis is matching drugs issued and investigations.
- Highlight
and identify exclusions from corporate (in terms of prescribed drugs) and
implement ways of reducing such rejections before claims are dispatched.
- Signing
on behalf of the doctor where the signature is missing.
- Filling
of claim forms on invoices without claim forms.
- Work
with the dispatch section to verify claims before they are dispatched.
Reconciliation
on Rejections regarding clinical issues and other returned invoices.
- Monitoring
invoice returns and taking appropriate action within a week from the date
of return on clinical issues and any query.
- Take
a lead in ensuring the reasons for returns are well addressed to avoid
future recurrence.
- Preparing
Rejection analysis on clinical issues and monthly reports as a tool to
guide the institution on the status of control.
- Work
with the Debtors team to review all the Clinical issues within the
reconciliation to sign off for the agreed period with corporate clients.
- Facilitate
closures to all rejected invoices on medical issues.
ICD-10
coding of claim forms
- Develop
proficiency in and familiarize oneself with the ICD-10 coding system and
coding tools.
- Develop
proficiency in and familiarize oneself with insurance scheme platforms,
including Smart, Slade, LCT, M-TIBA, and other relevant platforms.
- Develop
proficiency in and familiarize oneself with CareWeb ICD Voucher Wise ICD
entry and coding procedures.
- Ensure
100% of insurance claim forms requiring ICD-10 coding in CareWeb ICD
Voucher Wise are collated, accurately coded, and completed within the
stipulated turnaround time.
- Ensure
100% of insurance claim forms requiring ICD-10 coding on insurance scheme
platforms are collated, accurately coded, and completed within the
stipulated turnaround time.
- Aggregate,
review, and follow up on claims with missing or incomplete diagnoses on a
daily and weekly basis to facilitate timely and accurate coding and
submission.
- Participate
in all team efforts as departmental needs arise.
- Perform
other duties as may be assigned by the Manager.
The requirements
- Diploma
in Clinical Medicine or equivalent from a recognized institution
- Current
practicing Certificate
- Membership
registration to the relevant professional body.
- A
minimum of 3 years’ relevant experience in a busy Hospital or Insurance
- Results-driven,
ethical and adaptable professional with a strong service and stakeholder
focus.
- Strong
integrity with a sensitivity to manage confidential information.
