Medical Case Manager [Healthcare Services]

Monroe Consulting Group Indonesia is recruiting on behalf of an established healthcare group in Indonesia. Our client is seeking a qualified and experienced Medical Case Manager to oversee medical claims management and insurance verification processes across its hospital network.

Job 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-authorization, 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 standardize 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.
• Analyze claims performance, identify recurring issues, and recommend improvements to minimize 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.

Job Requirements

• Medical Doctor (dr.) qualification is mandatory.
• Previous experience in medical case management, medical claims review, insurance verification, or a related healthcare function.
• Strong understanding of private health insurance claims processes, medical documentation requirements, and insurance coverage assessment.
• Experience working in private hospitals, hospital groups, health insurance companies, or Third-Party Administrators (TPA) is preferred.
• Familiarity with medical necessity review, pre-authorization, guarantee letters, and claim dispute resolution.
• Ability to review clinical documentation and communicate effectively with medical professionals and insurance providers.
• Strong analytical skills with the ability to identify claim discrepancies, documentation gaps, and opportunities for process improvement.
• Experience coordinating or overseeing medical claims processes across multiple hospital units would be an advantage.
• Strong communication, problem-solving, and stakeholder management capabilities.
• Detail-oriented, organized, and capable of managing multiple priorities.
• Willing to be based in West Java.