Case Manager, Active Case Management at Jubilee Insurance

About the Role

We are seeking a qualified Case Manager to join our Active Case Management team. You will be responsible for managing inpatient pre-authorizations, claims processing, and 24-hour nurse line operations to support our members' healthcare needs while ensuring strict adherence to policy provisions and regulatory guidelines.

Main Responsibilities

Operational

• Make timely decisions on inpatient pre-authorizations and undertakings in line with policy limits and clinical appropriateness
• Review medical reports and documents to determine coverage and need for treatment
• Manage 24-hour nurse line operations on a shift basis to support round-the-clock member needs
• Verify membership eligibility and assess scope of benefits using scheme-specific records
• Vet and authorize inpatient services
• Liaise with underwriting and provider relations teams to ensure accurate interpretation of benefits and scheme terms
• Provide responses to client, provider, and internal queries regarding coverage, claim status, or treatment approvals
• Maintain accurate records for all case-related transactions
• Track turnaround time for all approvals and ensure timely processing and communication of decisions
• Support the team in meeting departmental SLAs and KPIs

Corporate Governance

• Ensure all inpatient authorizations and claims are reviewed and processed in strict adherence to policy provisions and regulatory guidelines
• Conduct thorough due diligence on approvals and declines, documenting all decisions accurately and consistently
• Vet all undertaking requests for completeness, validity, and compliance with insurance documentation standards
• Audit inpatient and outpatient claims to identify inconsistencies or potential fraud
• Confirm service validity against treatment given, provider rules, and cost thresholds
• Ensure all care management practices align with national healthcare regulations and medical ethics

Key Competencies

• Clinical knowledge and ability to interpret medical reports and treatment plans
• Understanding of health insurance policies, benefits, and scheme structures
• Strong case management and utilization review skills
• Analytical thinking and sound decision-making abilities