Job Description

Role Purpose

• Conduct comprehensive clinical and utilization assessments, distinguishing disease complexity and necessary treatment from potentially avoidable care, duplication, fragmented management, and unsupported service intensity. Develop individualized care plans in collaboration with clients, families, and healthcare providers.
• Critically appraise clinical guidelines and supporting evidence to assess medical necessity, treatment sequencing, monitoring requirements, and site-of-care appropriateness; document uncertainties and escalate decisions outside delegated authority. Coordinate with multidisciplinary teams to ensure cohesive care delivery.
• Investigate recurrent inpatient admissions, emergency attendance, and outpatient utilization across providers; identify underlying clinical, functional, behavioral, medication-related, and access barriers Conduct follow-up assessments to ensure ongoing support and intervention.
• Assess complex oncology and rare disease cases, recognizing when specialist consultation, multidisciplinary review, or a second medical opinion is required. Implement case management programs that address the needs of high-risk members.
• Work closely with other departments, such as authorisation, claims, and customer service, to ensure a seamless experience for members.
• Utilize data analytics to identify trends, assess program outcomes, and inform decision-making.
• Ensure all case management activities comply with relevant laws, regulations, and accreditation standards.
• Support ad-hoc projects within the department as needed, contributing expertise and ensuring timely delivery.
• Evaluate high-cost treatments, diagnostics, and procedures for appropriate indications, duplication, treatment response, and opportunities for clinically suitable alternatives.
• Engage members and caregivers through clear communication and shared decision-making; address barriers to adherence and sustained care-plan participation.
• Produce defensible case summaries, provider queries, escalation recommendations, and clinical justifications supported by documented evidence.
• Maintain accurate, timely, auditable documentation and comply with applicable confidentiality, regulatory, and organizational requirements.

Key Requirements and Qualifications

• Educational qualification: Bachelor’s degree in Medicine (MBBS/MD or equivalent), Nursing, Pharmacy, Physiotherapy, or another recognised allied health/paramedical discipline with relevant clinical training.
• Relevant experience: Minimum 2 years of experience in medical authorisation, claims assessment/adjudication, or case management within a health insurer, third-party administrator, or healthcare provider.
• Clinical assessment: Demonstrated ability to interpret medical records, understand diagnoses and treatment plans, evaluate clinical justification against evidence-based guidelines, and identify documentation gaps or cases requiring physician review.
• Insurance knowledge: Sound understanding of medical necessity, policy benefits and exclusions, authorisation and claims workflows, and the relationship between diagnosis, procedure coding, and reimbursement.
• Analytical capability: Ability to interpret claims and utilisation data, recognise recurrent admissions, excessive utilisation, fragmented care, and potentially avoidable expenditure, and translate findings into appropriate interventions.

Skills and Competencies

• Critical thinking and sound judgement: Ability to evaluate conflicting information, challenge assumptions, recognise uncertainty and reach well-reasoned conclusions within delegated authority.
• Investigative mindset: Intellectual curiosity and persistence in uncovering underlying causes, connecting information across sources and distinguishing meaningful patterns from isolated findings. Strategic thinking with strong focus on results and high quality of work
• Clear and persuasive communication: Translate complex information into concise, structured recommendations and adapt communication effectively for members, clinicians and business stakeholder
• Empathy and cultural sensitivity: Build trust, listen actively and handle sensitive discussions with professionalism and respect for diverse backgrounds.
• Ownership and execution: Demonstrate initiative, dependable follow-through and accountability for resolving issues and completing commitments.
• Prioritisation and adaptability: Manage competing demands, remain composed under pressure and adjust priorities appropriately when new information emerges.
• Digital fluency and learning agility: Confidently use Excel and digital systems, learn new tools quickly and critically assess the reliability of automated or AI-generated outputs.
• Collaboration and improvement mindset: Work effectively across disciplines, share knowledge, respond constructively to feedback and propose practical improvements.