Clinical Case Manager

by Tiana Liu in Healthcare    19th Apr, 2021       Beijing

Clinical Case Manager

Introduction:

The Clinical Case Manager has the primary goal of individual case management of medical cases as specified by the business to ensure quality care with special focus on 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 and case details. The Clinical Case Manager will have an integral role in the current case management process, as well as the claims audit and on-site case review.

Responsibilities:

  • Investigate, and respond to enquiries for complex medical authorisations and high value within certain threshold and criteria claims from members, providers, group secretaries, service partners and intermediaries in the appropriate method, in line with our 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 our 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 us
  • Liaise with all areas of the business to assist with resolving enquiries, such as claims eligibility, coverage and alternative treatments.
  • Works with audit and pre-authorization teams to identify and investigate any fraud or abuse.
  • Preparing case reports for each investigation performed; keeping record of daily activity for monthly reporting.
  • Identify opportunities to reduce future claim expense for us 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 our products, policies and initiatives in order to ensure that all queries are answered accurately.
  • Support our BGAIM medical teams to provide provider/specialist recommendation, estimate medical costs helping make appointment, support case management, etc. 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
  • Handling complaints and investigating the root cause to provide clear goal-oriented solutions

Requirements:

  • Excellent medical background with practical medical experience.
  • MBBS or nursing school degree.
  • Previous medical insurance experience is mandatory.
  • Superior customer service and negotiation skills.
  • Knowledge of clinical billing and coding is a must – Certified coding degree is a plus.
  • Basic knowledge of DRG system.
  • Excellent knowledge of Microsoft Word? and Microsoft Excel? is a must

We hope that you:
  • Good interpersonal and coordinating skill; good team work spirit.
  • Respects diversity and embraces cultural differences.
  • Willing to work outdoor with possible multiple visits per day.
  • Excellent record keeping and reporting skills, with ability to deliver reporting requirements in due time.
  • Understands the business commitment to meet deadlines and Turn-around times.
  • Good judgement and ability to prioritise workflow according to business needs.

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