Job Summary

The Case Manager is responsibly for coordinating care for enrollees, ensuring they receive the appropriate healthcare services in a timely and cost-effective manner. The Case Manager will work closely with healthcare providers, enrollees, and internal teams to facilitate treatment plans and manage healthcare cases. This role requires strong interpersonal skills to interact with both enrollees and providers, as well as the ability to manage and track multiple cases simultaneously. The Case Manager will also be responsible for ensuring that enrollees follow care plans, which may involve referral coordination, hospital admissions, or outpatient treatments.

Responsibilities

Care Coordination & Management

• Act as the primary point of contact for enrollees, coordinating all aspects of their care, from medical appointments to referrals.
• Work with healthcare providers to ensure that enrollees receive the right care at the right time, including inpatient and outpatient services.
• Track enrollee progress and ensure they follow their care plans, including attending scheduled appointments and undergoing necessary treatments.

Referral & Service Coordination

• Facilitate referrals to specialists or hospitals, ensuring proper documentation and pre authorization procedures are followed.
• Work with the provider relations team to ensure that service providers meet quality standards and are accessible for enrollee needs.
• Ensure that enrollees are informed of their rights and benefits under their health plans, guiding them through the referral process when necessary.

Case Review & Monitoring

• Regularly review and monitor medical cases to assess the effectiveness of treatment plans.
• Maintain accurate records of enrollee cases, including medical histories, treatments, and follow-ups.
• Ensure that care provided aligns with HMO guidelines and that enrollees are receiving medically necessary services.

Data Protection & Confidentiality

• Uphold the highest standards of confidentiality in handling company-related information, ensuring compliance with data protection laws and internal policies.
• Adhere to the company’s information security guidelines, including proper storage, transmission, and disposal of sensitive materials.
• Promptly report any suspected data breaches or unauthorized access to the appropriate company authority.
• Participate in periodic data protection training to stay informed about evolving security risks and best practices.

General Assignment

• Execute any other duties and tasks that may be designated or assigned by the Company.
• Participate in the knowledge sharing programme of the department and the company
• To provide supports to the Managing Director and Vice Chairman as may be required towards serving the Board, Management and staff.

Qualification

Education

• Bachelor’s degree in Nursing, Healthcare Administration, or related field.

Experience

• Minimum of 4 years of experience in case management or healthcare coordination, preferably within an HMO or health insurance setting.

Skills and Competencies

• Ability to coordinate and manage medical cases, ensuring timely and appropriate care for enrollees.
• Expertise in developing and implementing effective care plans for enrollees based on medical needs.
• Excellent communication skills to interact with healthcare providers, enrollees, and family members.
• Ability to address and resolve issues that arise during the care process, including coordinating with multiple stakeholders.
• Solid understanding of the healthcare system, insurance processes, and the HMO model for effective case management.

KPIs and Performance Metrics

1. Care Plan Adherence: Percentage of enrollees following prescribed care plans.
2. Enrollee Satisfaction: Improvement in enrollee satisfaction related to care coordination and case management.
3. Referral Efficiency: Timeliness in coordinating referrals and ensuring proper follow-up.
4. Cost Control: Effective management of cases to ensure that care is provided efficiently without unnecessary costs.
5. Health Outcomes: Improvement in health outcomes for enrollees through proactive care management and interventions.