Medical Case Manager (Healthcare Services)

Monroe Consulting Group; Jawa Barat; Presencial; IDR 200.000.000 - 400.000.000; Tempo integral

Resumo da vaga

Monroe Consulting Group, an Executive Recruitment firm, partners with a Healthcare organization in Indonesia to hire a Medical Case Manager. This role oversees medical claims management, insurance verification, and operational excellence across a hospital network.

The successful candidate will lead claims processing, coordinate with physicians and private insurers, ensure regulatory compliance, and drive performance improvements to minimise rejections and revenue leakage.

Qualificações

• Medical Doctor qualification is mandatory.
• Experience in medical case management, medical claims review, insurance verification, or related healthcare function.
• Experience in private hospitals, hospital groups, health insurers, or TPAs preferred.
• Willing to be based in West Java.

Responsabilidades

• Oversee private health insurance claims across hospital units for accuracy and timely submissions.
• Review medical records and docs to ensure private insurer compliance.
• Perform medical necessity reviews to assess service appropriateness.
• Coordinate with physicians, medical services, and hospital admin for docs.
• Liaise with insurers and TPAs on verification, pre-authorisation, letters.
• Monitor pending and disputed claims; identify root causes and fix issues.
• Develop standardised claims procedures across hospital units.
• Guide hospital teams on documentation and submission requirements.
• Analyse claims performance and suggest improvements to reduce leakage.
• Collaborate with corporate and hospital teams to align clinical, finance, insurance.
• Ensure compliance with healthcare regulations and internal procedures.
• Prepare regular reports on claims performance and outstanding items.

Conhecimentos

Analytical skills

Communication skills

Problem-solving

Detail-oriented

Process standardisation

Stakeholder management

Team collaboration

Formação

Medical Doctor (dr.) qualification

Descrição da vaga

Monroe Consulting Group, an Executive Recruitment firm, is partnering with an organisation in the Healthcare sector to hire a Medical Case Manager. This opportunity is based in Indonesia and offers a rewarding role overseeing medical claims management, insurance verification processes, and operational excellence across a hospital network.

Position Overview

Lead and coordinate medical claims management activities to ensure accurate, compliant, and timely insurance claim processing across multiple hospital units.
Drive operational efficiency, claims performance improvement, and effective collaboration between clinical, insurance, and administrative stakeholders.

Key Responsibilities

• Oversee and coordinate private health insurance claims processes across multiple hospital units to ensure accuracy, completeness, and timely submission.
• Review medical records, diagnoses, treatment procedures, and supporting documentation to ensure compliance with private insurance claim requirements.
• Conduct medical necessity reviews and assess the appropriateness of medical services and treatments in accordance with applicable insurance coverage.
• Coordinate with attending physicians (DPJP), medical services teams, and hospital administration to ensure proper medical documentation and claim justification.
• Liaise with private insurance providers and Third-Party Administrators (TPA) regarding claim verification, pre-authorisation, guarantee letters, and claim-related inquiries.
• Monitor pending, rejected, and disputed claims, identifying root causes and implementing corrective actions to improve claims acceptance rates.
• Develop and standardise medical claims management procedures across hospital units to ensure consistency and operational efficiency.
• Provide guidance to hospital-level insurance and medical administration teams regarding medical documentation and claim submission requirements.
• Analyse claims performance, identify recurring issues, and recommend improvements to minimise claim rejections and revenue leakage.
• Collaborate with relevant corporate and hospital stakeholders to strengthen coordination between clinical services, finance, and insurance administration.
• Ensure compliance with applicable healthcare regulations, insurance policies, and internal hospital procedures.
• Prepare regular reports on medical claims performance, outstanding claims, and operational improvement initiatives.

Qualifications & Experience

• Medical Doctor (dr.) qualification is mandatory.
• Previous experience in medical case management, medical claims review, insurance verification, or a related healthcare function.
• Experience working in private hospitals, hospital groups, health insurance companies, or Third-Party Administrators (TPA) is preferred.
• Experience coordinating or overseeing medical claims processes across multiple hospital units would be an advantage.
• Willing to be based in West Java.

Technical / Functional Expertise

• Strong understanding of private health insurance claims processes, medical documentation requirements, and insurance coverage assessment.
• Experience in medical claims review, insurance verification, and healthcare reimbursement processes.
• Familiarity with medical necessity review, pre-authorisation, guarantee letters, and claim dispute resolution.
• Ability to review clinical documentation and assess the appropriateness of medical services and treatments.
• Strong knowledge of medical claims management procedures and claims performance monitoring.
• Experience liaising with private insurance providers and Third-Party Administrators (TPA).
• Ability to identify claim discrepancies, documentation gaps, and revenue leakage risks.
• Experience preparing reports on claims performance, outstanding claims, and operational improvement initiatives.
• Understanding of healthcare regulations, insurance policies, and hospital administrative procedures.

Soft Skills & Leadership Competencies

• Strong analytical skills with the ability to identify recurring claims issues and recommend practical solutions.
• Excellent communication skills with the ability to engage effectively with medical professionals, insurance providers, and hospital stakeholders.
• Strong problem-solving and stakeholder management capabilities.
• Detail-oriented, organised, and capable of managing multiple priorities.
• Ability to drive process standardisation and operational efficiency across multiple hospital units.
• Strong collaboration and coordination skills across clinical, finance, insurance, and administrative functions.
• Commitment to accuracy, compliance, and continuous improvement in claims management processes.