Medical Case Manager jobs

Overview

We are recruiting on behalf of a growing client in the US seeking a highly detail-oriented and proactive Medical Authorisations & Denials Specialist to support their healthcare operations team.

This role is focused on managing insurance authorisations, following up on denied claims, and ensuring timely approvals and reimbursement processes within the American healthcare system. The ideal candidate will have strong experience working with medical insurance, payer communication, and healthcare administration processes.

Candidates with prior US healthcare experience are strongly preferred. However, candidates with strong South African medical aid authorisations or healthcare administration experience and the ability to adapt quickly to the US system will also be considered.

Key Responsibilities

• Submit and manage prior authorisation requests with insurance providers
• Follow up on pending authorisations to ensure timely approvals
• Investigate and resolve denied or rejected claims
• Communicate with insurance companies regarding authorisations, denials, appeals, and claim status updates
• Prepare and submit appeals with supporting documentation where required
• Maintain accurate records of authorisation and denial activity
• Work closely with internal teams to obtain required clinical or billing information
• Monitor payer portals, fax communications, and insurance correspondence
• Escalate unresolved issues appropriately and provide regular updates to management
• Ensure all work is completed accurately and within required turnaround times

Requirements

• Previous experience in medical authorisations, denial management, medical billing, revenue cycle management, or healthcare administration
• Experience working within the US healthcare system is highly advantageous
• Candidates with South African medical aid authorisations or hospital administration experience are encouraged to apply
• Strong understanding of insurance processes, claims workflows, and payer communication
• Excellent verbal and written English communication skills
• Strong attention to detail and organisational skills
• Comfortable handling high volumes of follow-ups and administrative tasks
• Ability to work independently and manage multiple priorities effectively
• Experience with EMR/EHR systems, payer portals, and healthcare software is beneficial
• Ability to work aligned to US business hours (EST/CST preferred)

Preferred Experience

• Prior experience handling insurance denials and appeals
• Knowledge of CPT, ICD-10, and medical terminology
• Experience working in behavioural health, ABA, therapy, or outpatient medical environments is advantageous
• Familiarity with commercial insurance providers and Medicaid processes

Working Hours

• Full-time
• Aligned to US business hours (EST/CST)

Location

• Remote (South Africa)