Sr. Specialist - AAGI A&H Case management - UR

Job description

Being responsible for concurrent process or case management team in accordance with Medical necessity and Utilization Management policies and procedures. Concurrent process is a middle process between admission case was approved and discharged process. Daily concurrent review and long stay admission (more than 3 days) case and complex case which has to be concurrent reviewed and cost containment by case management team.

1). Reviews claim and medical reports (medical indication assessment). - Concurrent review pre-authorised admission case following the Complex Case Management Guidance.

    - Review and manage the treatment of high claiming members to ensure that their treatment is appropriate and automatic referral to the medical team if criteria is met.

    - Cost containment by verify the eligibility of claims, Length of Stay Management, providing the Alternative Pathway of Treatment which is beneficial for member and cost effective.

    - Refer and consult  the Medical consultant for all cases that do not meet established guidelines for admission or continued stay.

    - Review Third Party Recovery & Fraud.

2). Applies all medical necessity guidelines (Thai Medical Practice Guidelines), determine coverage and apply all cost containment measures to assist during the claim adjudication process.

    - Ensure that any new clinical procedures, drugs or technology are appropriate and safe for our customers.

    - Study and understand A&H policy & coverarge to apply concurrent review and case management tasks.                                                                                                                                                                                                                                                                                                                                                            

3). Detects suspicious, fraud or abuse claim by providers and refer to Clinical  Governance Team.                                                                                                                                                                                                                                                                                                                                                                                      

4). Process Coding (ICD codes) based on medical procedures and the claim process.                                                                                                                                                                                                                                                                                                                                                                             

5). Record cost saving report and monthly concurrent review productivity report.                                                                                                                                                                                                                                                                                                                                                                           

Qualifications :

1. Minimum 3 years in nursing experience.

2. Nurse in critical units such as ER, ICU, OR will be an advantage.

3. Able to work in commercial environment and fast moving business.

4. Excellent interpersonal and communication skills.

5. Any AI-future skills e.g., ChatGPT, or CoPilot 365, will be an advantage.