Care Officer – Case Management

Position Overview

The Care Officer role delivers clinical oversight and case management for insured members requiring hospitalization. This position ensures members receive medically appropriate, high-quality, and cost-effective care while safeguarding the financial sustainability of the medical scheme. The role involves evaluating pre-authorizations, monitoring inpatient admissions, and coordinating with healthcare providers. It requires strong clinical acumen, deep understanding of medical insurance operations, benefit structures, and regulatory requirements.

Key Responsibilities

• Ensure proper care and treatment of patients within acceptable protocols to mitigate overuse of cover by members and providers
• Vet and review claim documents to determine validity, eligibility, and benefits in accordance with policy guidelines
• Prepare daily reports of admissions across various service providers
• Attend to customer inquiries and escalate complicated and disputed cases through the call centre, ensuring resolution within agreed timelines
• Process claims within provider payment schedule timelines
• Obtain additional required information on claims from providers, brokers, or clients through pre-authorization forms and scrutinize forms for correct diagnosis
• Undertake patient visits to ensure quality service, correct treatment, and eligibility verification; explain medical terms of cover where queried
• Inform the provider management team of any anomalies in provider service or quality concerns
• Review and resolve complex cases, providing appropriate clinical expertise on diagnosis and treatment within policy coverage; escalate cases where necessary for medical guidance

About This Opportunity

This position offers a strong opportunity for career growth within a dynamic medical insurance environment.