The Medical Care / Case Manager is responsible for providing clinical oversight and end-to-end case management support for medical insurance claims. The role ensures appropriate utilization of medical benefits, timely and efficient claims processing, effective coordination with hospitals, TPAs, clients, and intermediaries, and protection of ICEA LION’s financial and reputational interests.
The position plays a critical role in enhancing service delivery, improving turnaround times, strengthening provider relationships, and supporting wellness and risk management initiatives.
Key Responsibilities
Clinical Oversight & Case Management Support
- Audit and clinically review TPA pre-authorizations to ensure medical necessity, policy compliance, benefit limits, and cost appropriateness in line with ICEA LION medical underwriting guidelines.
- Monitor hospital admissions in real time to ensure early intervention, appropriate length of stay, and adherence to agreed treatment protocols.
- Conduct physical visits to admitted members in hospitals as an official representative of ICEA LION.
- Liaise with treating doctors and hospital medical teams to clarify treatment plans, expected outcomes, and estimated costs.
- Provide professional clinical input on complex, high-cost, or long-stay cases and advise on cost-containment strategies where appropriate.
- Support escalation and resolution of medically complex or sensitive cases to ensure quality care and timely decision-making.
Provider & TPA Coordination / Supervision
- Act as the primary medical liaison between ICEA LION, hospitals, and Third-Party Administrators (TPAs).
- Handle and resolve provider-related issues, including billing discrepancies, clinical disputes, service quality concerns, and admission or discharge delays.
- Monitor and track TPA turnaround times on pre-authorizations, admissions, discharges, and claims processing to improve efficiency and meet agreed service level agreements (SLAs).
- Proactively engage TPAs to address bottlenecks and drive continuous improvement in hospital engagement and service delivery.
- Create and maintain ICEA LION brand visibility in hospitals through professional presence, relationship management, and consistent communication.
- Support onboarding and evaluation of providers to ensure alignment with ICEA LION standards and expectations.
Client & Intermediary Engagement
- Engage directly with corporate clients and intermediaries (brokers and agents) on claims-related matters, benefit interpretation, and coverage clarifications.
- Provide clear, accurate, and timely medical and policy guidance to manage expectations and enhance client confidence.
- Support client retention by proactively addressing service concerns and ensuring a positive claims experience.
- Lead and participate in wellness engagement initiatives, including health talks, awareness campaigns, and preventive care programs.
- Coordinate wellness activities with doctors, hospitals, TPAs, and other relevant partners in line with ICEA LION’s wellness strategy.
- Provide feedback to internal teams on client and intermediary insights to inform service improvements and product enhancements.
Risk Management & Analytics
- Identify, flag, and investigate potential fraud, abuse, or overutilization trends across providers, members, or benefit categories.
- Monitor high-cost, repeat, or unusual claims patterns and recommend corrective actions or benefit management strategies.
- Support medical audits, utilization reviews, and post-claim reviews to safeguard ICEA LION’s financial exposure.
- Prepare analytical reports and insights on claims trends, provider performance, utilization patterns, and emerging medical risks.
- Collaborate with underwriting, actuarial, and claims teams to inform pricing, benefit design, and risk mitigation strategies.
Qualifications & Experience
- Bachelor’s degree in Nursing, Clinical Medicine, or a related healthcare field.
- Valid professional registration with relevant medical or nursing bodies.
- Minimum of 3–5 years’ experience in medical case management, hospital operations, insurance, or TPA environment.
- Strong understanding of medical insurance policies, claims processes, and healthcare delivery systems.
- Experience working with hospitals, TPAs, and corporate clients is an added advantage.
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