Overall responsibility:
Care Management, handling Inpatient preauthorizations, and communicating with providers, clients, and brokers on a timely basis for any undertakings, rejections, or relevant concerns. Doing proper case management by doing physical visits and virtual follow up of all admitted members.
Key Responsibilities
Care Management – Through due diligence, ensuring undertakings are issued in line with the policy provisions. Likewise, for declines, ensuring that the decisions are accurate and a correct interpretation of the policy
Ensure appropriate Turnaround Time is adhered to in issuing approvals.
Seeking medical clarifications including medical reports, copies of investigation reports
Broker/customer relations by communicating all necessary admission claim decisions on a timely basis.
Work with the claims team and coordinating on any information noted in the claims especially inpatient claims submitted in cases where further information provided changes the position undertaken previously on the claim.
Reviewing medical pre-authorizations for compliance with applicable policy guidelines.
Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is legal, ethical and consistent with the principles of the policy.
Visiting/engaging admitted patients and ensuring they receive quality and cost-effective quality care
Engaging providers on matters cost, discounts, pre-agreed rates, packages, fixed cost model
Checking and confirming membership validity and benefits (from the scheme benefits file)
Handling of coverage enquiries with brokers, providers, members etc.
Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.
Obtaining additional required information on claims from providers, brokers or clients
Ensure accurate information is captured in the system and have a zero-error rate in benefit adjudication of all cases
Liaising with underwriting section on scope of cover for various schemes
Liaising with provider relations section on matters pertaining to provider panel, customer complaints etc
Client presentations and member education on wise utilization & risk management
Support the care management team to ensure all the deliverables are met within the given turnaround time
Skills and Competencies Required
Health Benefits Plan Management
Policy Interpretation
Customer Service and Focus
Ownership & commitment
Team Spirit
Excellent communication
Ability to multi-task
Strong negotiation and decision-making skills
Knowledge & Experience
At least 2 years' case management experience in a medical insurance environment
Demonstrated knowledge of managing admissions and discharges in a busy insurance company
Demonstrated experience in engaging service providers and doctors and negotiating cost
Demonstrated experience in case management reports, physical visits, virtual follow up of admitted cases
Academic and Professional Qualifications required
Bachelor's degree in nursing or clinical medicine
At least two-year's experience in a case management role.