Case Management Specialist

About the RoleThe Case Management Specialist is responsible for reviewing, assessing, and coordinating cashless medical services to ensure each request aligns with policy provisions, medical necessity, and clinical standards. This role plays a key part in the guarantee assessment process—from initial document review to final benefit calculation—while ensuring accurate decisions, smooth communication with stakeholders, and efficient coordination with hospitals. You will help ensure members receive appropriate care while maintaining high service accuracy and operational efficiency.Key ResponsibilitiesAnalyze initial medical documents submitted for guarantee assessment to ensure accuracy and completeness for early decision-making.Monitor cashless guarantee and claim processes, including verbal confirmations and supporting medical documentation, to ensure timely and efficient service delivery.Review and Assess final medical documents to support accurate and compliant guarantee decisions.Calculate final benefit outcomes according to policy provisions and benefit limits to ensure fair and consistent guarantee results.Communicate guarantee decisions by collaborating with Medical Advisors and explaining outcomes to clients for clarity and transparency.Coordinate with hospitals to obtain complete, accurate medical documentation and participant information to support smooth case processing.Evaluate the medical reasonableness of proposed procedures and surgeries to ensure alignment with the participant’s medical condition and clinical standards.RequirementsBachelor’s degree in Nursing.Minimum 3 years of experience in case management or claim analysis within life insurance or TPA environments.Experience working in a reputable hospital or healthcare facility is an advantage.PAMJAKI and AAAIJ certifications is an advantage.Strong medical background with the ability to interpret clinical information.Familiarity with insurance claim procedures, benefit structures, and cashless claim processes.