China Case Manager

by Tiana Liu in Insurance/Pension funding    3rd Apr, 2020       Beijing

China Case Manager

Introduction:

• With the primary goal of individual case management of medical cases as specified by the business to ensure quality care whilst balancing financial savings. • This role ensures that all parties (broker, company, provider, service partner, colleagues) involved are kept up to date on the progress of authorisation.

Responsibilities:

• Investigate, and respond to enquiries for complex medical authorisations and high value claims from members, providers, group secretaries, service partners and intermediaries in the appropriate method, in line with Bupa Global policy and management style. • Pro-actively contact members, providers, service partners and intermediaries via telephone, email, fax and letter to advise on decision of request and fully explain benefit entitlement to all parties. • Ensure the correct interpretation of Bupa Global’s policy and rules, using the correct compatible combinations of codes for accurate processing of data, in accordance with our service standards and customer expectations • Liaise with Global clinical staff to interpret condition and treatment to the rules and regulations of Bupa Global • Liaise with all areas of the business to assist with resolving enquiries, such as underwriting and claims • Provide advice to front line staff to support the process of pre-authorisation across the region • Identify opportunities to reduce future claim expense for Bupa Global and to pro-actively provide relevant information to Risk management department • Proactively negotiate medical costs and/or medical treatment to achieve either reduced cost to the business or most appropriate treatment for member • Develop and maintain an up to date and accurate knowledge of appropriate Bupa products, policies and initiatives in order to ensure that all queries are answered accurately • Support Bupa Global Greater China operation team on medical knowledge and advice • Backup HK/China Case Manager for BGGC case management. Achieve departmental and individual KPIs • Take responsibility for the logging of written queries and complaints on the customer database, ensuring it is up to date and as accurate as possible • To comply with and take into account any requirements from the local regulators and/or any applicable local regulatory requirements • Support Pre-auth / medical review / provider enquiry in HK or China Delivering fair outcomes for consumers and Understanding your regulatory obligations: • Put fair treatment of customers at the heart of what you say and do. Be courageous and speak up if you believe our products or services do not deliver what we have led our customers to expect. • Be accountable and take ownership for ensuring you are familiar with all regulatory requirements that fall within the remit of your role and comply with them at all times. Seek guidance if you need support understanding your regulatory requirements. Notify, without delay, any potential or actual breach of regulation. • To maintain governance and control requirements, ensuring all internal governance requirements are met, including full compliance with all policies, audit actions, monitoring actions and risk appetite.

Requirements:

• University degree in any discipline, but preferred in medical or the related major • Preferably with medical or nursing background • Experienced professional with knowledge of the HK/China Healthcare market • Knowledge and understanding of health insurance products and handling health insurance claims • Excellent experience in understanding medical issues and being able to read and understand complex medical journals and cases • Ability to be empathetic and view issues from the customer’s perspective whilst maintaining professional and friendly attitude • Ability to create and keep overview and solve complex issues • Keeping a pro-active mind-set • Significant knowledge and cultural understanding of the various regions and its market • An ability to speak fluent English and Mandarin and Cantonese (for HK) is needed • Excellent interpersonal, communication and influencing skills are required with emphasis on achieving results and successful outcomes • Ability to inspire and create enthusiasm, energy and cooperation in others to achieve work objectives • Proficient in negotiation with healthcare providers (doctors, hospitals, etc) to manage claim costs, including challenging providers regarding care pathways and treatment plans, negotiating reasonable and customary rates, discounts etc. • Demonstrated understanding of contact centre practices, dependencies and operations (desirable) • Effective knowledge of Bupa products, systems, policy, internal structure and function (desirable)

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