Case Manager, TRICARE Overseas Program (TOP)

The Role

The Case Manager for the TRICARE Overseas Program (TOP) plays a pivotal role in delivering comprehensive case management services to individuals and families with complex healthcare needs. This role involves active collaboration with healthcare providers, beneficiaries, and multi-disciplinary teams to ensure high-quality, cost-effective medical outcomes. The successful candidate will manage cases with high-cost or intricate medical conditions, offering tailored care coordination both telephonically and in person. This position offers the opportunity to work within an internationally focused healthcare programme, supporting beneficiaries globally and contributing to continuous service improvement.

Responsibilities

Key Responsibilities:

• Collaborate effectively with internal teams, external subcontractors, the Defense Health Agency, and TRICARE beneficiaries to ensure seamless case management delivery.
• Maintain professionalism and empathetic communication when engaging beneficiaries and stakeholders across diverse cultural backgrounds.
• Manage case assignments through the CRM system, ensuring timely outreach and ongoing engagement with beneficiaries.
• Apply clinical knowledge to evaluate medical necessity and appropriateness of care plans and treatments, ensuring alignment with evidence-based standards.
• Document clinical progress comprehensively using the CRM system, preparing detailed case summaries for monthly review meetings.
• Facilitate proactive disease education, medication reconciliation, and goal-setting conversations tailored to individual beneficiary needs.
• Coordinate with regional healthcare providers to verify adherence to international standards and optimize patient care pathways.
• Participate in quality assurance activities including internal audits, surveillance audits, and case review meetings to support programme integrity and continuous improvement.
• Address and escalate beneficiary concerns regarding billing, policy, or claims to appropriate management channels promptly.
• Engage in continuing professional education and attend regular team meetings to enhance knowledge and align with evolving programme protocols.
• Demonstrate accountability for case management workload, maintaining accurate documentation and prioritizing tasks to meet service delivery targets.
• Contribute to reporting and procedural updates, serving as a subject matter expert on case management policies and standard operating procedures.

Requirements

Essential Requirements:

• Registered nursing qualification with current licensure valid in the country of practice.
• Minimum of three years’ clinical nursing experience, preferably with exposure to case management or managed care environments.
• Strong foundation in broad medical knowledge, enabling effective assessment and coordination of complex healthcare scenarios.
• Proven ability to communicate clearly and professionally in English, both verbally and in writing, including writing detailed clinical summaries and reports.
• Demonstrated skills in problem-solving, critical thinking, and the ability to work proactively to identify and address potential challenges in patient care.
• Experience with or knowledge of international healthcare systems and standards is advantageous, especially familiarity with the TRICARE Overseas Program.
• Competence in using Microsoft Office and learning bespoke healthcare database systems, including CRM platforms.
• Ability to work effectively under pressure, managing multiple cases while maintaining attention to detail and accuracy.
• Exemplary interpersonal and cultural sensitivity skills to effectively manage interactions with diverse beneficiary populations and international teams.
• Motivated and self-directed with a commitment to continuous professional development and adherence to ethical standards of practice.