Role Purpose
The Care Manager is a clinically trained professional at the heart of ACS's medical operations function. The role carries three interconnected responsibilities: adjudicating pre-authorizations with speed and clinical accuracy, negotiating medical costs with healthcare providers during active admissions and service delivery, and providing sound clinical guidance to members navigating the healthcare system.
A particularly critical aspect of this role is the ability to step down care — identifying situations where a member can receive equivalent quality of treatment at a more cost-effective facility or care setting, and facilitating that transition in a way that is clinically safe, member-centred, and clearly communicated. The Care Manager must balance advocacy for the member's health outcomes with stewardship of scheme sustainability.
The ideal candidate is a clinically confident, commercially aware healthcare professional — typically a registered nurse or clinician with managed care experience — who can make sound, defensible clinical decisions under time pressure while maintaining strong relationships with providers, members, and internal teams.
Key Accountabilities
Care Coordination & Case Management
- Coordinate and manage care plans for assigned members.
- Conduct clinical assessments and evaluate members' healthcare needs.
- Monitor admissions, ongoing treatment, referrals, and discharge processes.
- Facilitate continuity of care across healthcare providers and service points.
- Ensure timely escalation of critical and emergency cases.
Utilization Management
- Review treatment plans to ensure appropriateness, quality, and cost-effectiveness.
- Facilitate pre-authorizations and care approvals in accordance with clinical guidelines.
- Monitor healthcare utilization and identify opportunities for cost containment.
- Support interventions aimed at reducing unnecessary admissions and readmissions.
Provider & Stakeholder Engagement
- Liaise with healthcare providers to coordinate member care and treatment plans.
- Collaborate with internal teams to ensure seamless service delivery.
- Participate in provider engagements, case reviews, and clinical discussions.
- Foster positive relationships with members, providers, and other stakeholders.
Chronic Disease & Wellness Management
- Monitor high-cost, chronic, and complex medical cases.
- Support disease management and wellness initiatives.
- Promote preventive healthcare and member education programs.
- Guide members on available healthcare resources and treatment options.
Member Advocacy & Experience
- Act as an advocate for members throughout their healthcare journey.
- Provide guidance on benefit utilization and access to care.
- Address member concerns and facilitate timely resolution of service issues.
- Support initiatives aimed at improving member satisfaction and outcomes.
Clinical Quality & Compliance
- Ensure adherence to clinical protocols, policies, and regulatory requirements.
- Participate in clinical audits, quality reviews, and risk management activities.
- Monitor quality indicators and recommend improvement initiatives.
- Support implementation of evidence-based clinical practices.
Reporting & Documentation
- Maintain accurate and up-to-date clinical records and case documentation.
- Prepare care management, utilization, and case review reports.
- Track and report on key care management metrics and outcomes.
- Ensure confidentiality and proper management of member information.
Key Performance Indicators
- Member Care Coordination
- Quality of Clinical Outcomes
- Case Management Effectiveness
- Timeliness of Pre-Authorizations
- Member Satisfaction
- Care Plan Compliance
- Hospitalization and Readmission Management
- Utilization Management Effectiveness
Qualifications
- Bachelor's Degree or Diploma in Nursing, Clinical Medicine, Medicine, Pharmacy or a related healthcare field.
- Valid professional registration and licensing where applicable.
Added Advantage
- Professional qualification in AIIK, ACII, or Certificate in Insurance.
- Formal training in customer experience or call centre operations.
- Knowledge of medical scheme operations, SLAs, and healthcare provider management.
- Understanding of ISO Quality Standards and Data Protection Act compliance.
Experience
- Minimum of 2 years' experience in case management, utilization management, clinical care, managed care, medical insurance, or healthcare administration.
- Experience in a medical insurance, TPA, healthcare management, or managed care environment is preferred.
- Knowledge of healthcare benefits, pre-authorizations, and clinical protocols.
Core Competencies
- Clinical assessment and decision-making skills
- Case management expertise
- Patient advocacy and member support
- Strong communication and interpersonal skills
- Analytical and problem-solving abilities
- Relationship management
- Attention to detail
- Report writing and documentation
- Time management and prioritization
- Professional integrity and confidentiality