Long Term Insurance

Case Manager

Sandton, Gauteng
Work Type: Full Time

Registered Nurse with case management experienced needed in the insurance sector!

Scope of Responsibility:              

•            Overall responsibility for incoming calls from Hospitals Case Managers relating to authorisations for procedures in Hospitals, Casualty, Specialist, GP, or Dental provider rooms.

•            Hospital case management from issuing a guarantee of payment (GOP) to final discharge and any follow-up treatment where required.

•            All medicines-related issues for special cases and off formulary items.

•            Analyse clinical, utilisation, and other data of members and healthcare providers.

•            Share data and interventions with others within the managed care and administration teams, ensuring optimal patient care and minimising utilisation.

•            Identify trends in utilisation, fraud, and other factors.

•            Ensure that all calls and cases are fully recorded on the MIP system accordingly.

•            Ensure efficient Customer Service and compliance to agreed SLAs.

•            Follow up with GP providers who may be overutilizing the “in rooms” procedures.

•            Manage and maintain data integrity and update accordingly where necessary.

•            Provide input and/or develop other processes to manage utilisation more efficiently.

•            Ensure all enquiries are resolved satisfactorily and customer requirements within business rules and costing factors are maintained.

•            Regularly review all approved claims and ensure that all are settled according to correct tariffs and procedures.

•            Supply all monthly management reports.

•            Any other duties as assigned by the company from time to time.


•            Matric

•            Registered Nursing diploma

•            Valid membership of SANC

•            Claims and Forensic Risk management certification

•            Registration with the Association of Certified Fraud Examiners (ACFE SA)


Skills and Experience: 

•            At least 2-3 years of experience in a similar role.

•            MIP Application System experience and advantage.

•            Sound understanding of the South African Health Industry, benefits, options, etc.

•            ICD codes, modifiers, and RPL tariff knowledge and understanding.

•            Ability to liaise with external parties – clinicians and members.

•            Ability to work within an established team.

•            Excellent oral and written communication skills.

•            Customer-centric attitude.

•            Excellent analytical skills and pays attention to detail.

•            Computer literate - MS Office suite, i.e. Word, Excel.

•            A good understanding of claims risk profiling.

•            Experience in claims auditing.

Talent Partner:
Misan Idowu

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