Case Management Specialist

12 hours ago

Jakarta Metropolitan Area, Indonesia MSIG Life Full time

About the Role

The
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 Responsibilities

  1. Analyze
    initial medical documents submitted for guarantee assessment to ensure accuracy and completeness for early decision-making.
  2. Monitor
    cashless guarantee and claim processes, including verbal confirmations and supporting medical documentation, to ensure timely and efficient service delivery.
  3. Review and Assess
    final medical documents to support accurate and compliant guarantee decisions.
  4. Calculate
    final benefit outcomes according to policy provisions and benefit limits to ensure fair and consistent guarantee results.
  5. Communicate
    guarantee decisions by collaborating with Medical Advisors and explaining outcomes to clients for clarity and transparency.
  6. Coordinate
    with hospitals to obtain complete, accurate medical documentation and participant information to support smooth case processing.
  7. Evaluate
    the medical reasonableness of proposed procedures and surgeries to ensure alignment with the participant's medical condition and clinical standards.

Requirements

  1. Bachelor's degree
    in Nursing.
  2. Minimum 3 years of experience
    in case management or claim analysis within life insurance or TPA environments.
  3. Experience working in a reputable
    hospital or healthcare facility
    is an advantage.
  4. PAMJAKI
    and
    AAAIJ
    certifications is an advantage.
  5. Strong
    medical background
    with the ability to interpret clinical information.
  6. Familiarity with
    insurance claim procedures
    , benefit structures, and cashless claim processes.

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