Senior Case Management Officer – Wellness & Provider Relations

Key Responsibilities

• Ensure the delivery of quality and affordable care to all admitted patients.
• Analyze and interpret admission, savings, and average cost reports for effective cost control.
• Manage the enrollment of members into the Chronic Disease Management (CDM) program and conduct follow-ups.
• Collaborate with the wellness team to ensure compliance.
• Verify and audit outpatient and inpatient approval requests according to the claims manual and customer service charter manual to ensure compliance and mitigate risk.
• Supervise, train, and mentor case management officers to achieve high productivity and motivation within the team.
• Negotiate professional fees and hospital charges, including discounts, to control medical expenditure.
• Conduct regular business meetings with service providers to ensure compliance with contract terms, tariffs, and systems.
• Monitor, prevent, and control medical claims fraud by carrying out regular audits on internal and external systems/processes as well as providers.
• Prepare regular care reports for clients and management; advise the medical underwriting section on relevant care findings for medical risk review.
• Operate within the approved Delegated Authority Matrix and perform other assigned duties.

Requirements and Qualifications

• Diploma or Degree in Nursing, Clinical Medicine, or Pharmacy.
• Professional qualification in Insurance (ACII, FLMI, or IIK) is an added advantage.
• 6-8 years of experience in medical claims handling, with at least 2 years in a supervisory position within a busy insurance environment.
• Deep knowledge of insurance concepts and products.
• Understanding of insurance regulatory requirements.
• Proficiency in sales and marketing management skills.

How to Apply

Interested and qualified candidates should apply online through the Britam recruitment portal on Taleo. You can access the application page directly via Britam on britam.taleo.net.