Care Manager at Madison Group Limited

Duties and Responsibilities

Care Management, handling Outpatient, Optical, Dental, and inpatient preauthorization, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns.

The role will provide support for Healthcare Businesses by;

1. Care Management - Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise, for declines, ensuring that the decisions are accurate and a correct interpretation of the policy
2. Ensure appropriate Turnaround Time is adhered to in issuing approvals.
3. Seeking medical clarifications including medical reports, copies of investigation reports, etc
4. Broker/customer relations by communicating all necessary admission claim decisions on a timely basis.
5. Work with the claims team and coordinate on any information noted in the claims, especially inpatient claims submitted in cases where further information provided changes the position undertaken previously on the claim.
6. Reviewing medical pre-authorizations for compliance with applicable policy guidelines.
7. Interacting with clients, brokers, and clinicians as needed, to resolve problems in a manner that is legal, ethical, and consistent with the principles of the policy.
8. Visiting/engaging admitted patients and ensuring they receive quality and cost-effective quality care
9. Engaging providers on matters of cost and discounts
10. Checking and confirming membership validity and benefits (from the scheme benefits file)
11. Handling coverage inquiries with brokers, providers, members, etc.
12. Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules, and cost of treatment.
13. Obtaining additional required information on claims from providers, brokers, or clients
14. Liaising with the underwriting section on the scope of cover for various schemes
15. Client presentations and member education on wise utilization & risk management
16. Managing the 24-hour emergency helpline

Support the care management team to ensure all the deliverables are met within the given turnaround time.

Qualifications and Work Experience

1. Customer Focus
2. Ownership & commitment
3. Team Spirit
4. Excellent communication
5. Ability to multi-task
6. Bachelor’s degree in nursing / Diploma in nursing or clinical medicine

Functional Skills

1. Health Benefits Plan Management
2. Policy Interpretation
3. Customer Service