Sr. Specialist - AZAY Medical Management and Utilization Review

Job description

Job responsibilities:

1) Medical Utilization Management
- Perform concurrent reviews and on site for patients using Health Integrated behavioral health criteria (Indication of admission and Length of Stay as a guideline, calculates the lengths of stay and continued-stay days for patients) to ensure that the indication of admission and extended stays are medically justified and are so documented in patient's medical records.
- Collect only pertinent clinical information and document all UM review information using the appropriate software system - Refer to the Utilization Review Physician for all cases that do not meet established guidelines for admission or continued stay.
- Identify problems related to the quality of patient care and refer such problems to medical director.
- Collect and summary concurrent review report as assigned area every month and send all data to analyz by Medical analysis to be sent to the hospital network.
- Perform other duties as requested by Manager or Medical Director

'2) Allianz Ayudhya Care Hospital Network and Medical Claim Analysis
- On-site and internal reviews and utilization survey with clients to evaluate services received and documents evidence through interview/investigative reports as assigned.
- Communicate with hospital networks to resolve instances of inappropriate utilization - Prepare the Abuse/Miss utilization Report to management

'3)  Medical Services and Administration
3.1 Panel Physician                                                                                                                                                     
- Select and appoint Panel physician from hospital or clinic  for pre-insurance checkup customer of Allianz Ayudya hospital network                                                                                   - Prepare letter that appoint Panel physician and send out to director of hospital or clinic                           - Prepare and update data of appoint Panel Physician and coordinate with IT to communicate to agency via web
3.2 Mobile Medical Service                                                                                                                                         
- Manage MMS service by receiving requests from agents and answer enquires regarding to Mobile Medical Service and register the request coordinate with medical mobile team to provide the services as scheduled       - Prepare document such Contract , PA policy and payment of MMS team to relavant party every month 
- Prepare Medical report in Pre-insurance Checkup case that customer  request their results                  
3.3 Medical room                                                                                                                                                         
- Manage Medical room facilities such as nurse, medical consultant, medical supply (medicine, equipment)    
- Prepare report and payment for physician fee such as ECG, CxR, Orasure, doctor fee, Bria Lob, PRO lab and medical expense to relavant party every month                                     

'3.4.Coordinate with Marketing team for Prestige program                                                                                  
- Prepare activiities by coordinate with Marketing/Group Business to contact with marketing dept of hospital network to provide special campaigns for prestige customer or specific group customer         
3.5  Med-incomplete management                                                             - Coordinate with underwriter by receiving the medical examination documents from underwriter such as incorrect or incomplete to review and provide feedback to physician and nurse, and provide the formal letter to physician and nurse                                                                                                          
3.6 Medical E-Newsletter                                                                                                                                          
- Prepare the information regarding to Medical Management and Medical service (e.g. New  Allianz Ayudhya hospital network , New Check-up Centre) to provide also update the health tips to publish in    E-Newsletter to Sales Channels via email on a monthly basis                                                                        
- Select and appoint Panel physician from hospital or clinic  for pre-insurance checkup customer of Allianz Ayudya hospital network                                                                                  - Prepare letter that appoint Panel physician and send out to director of hospital or clinic                          
- Prepare and update data of appoint Panel Physician and coordinate with IT to communicate to agency via web

'4) General Management
- Support project collaboration e.g. Hospital Service Awards.
- Customer focus e.g. Handle complaint from customer - Communicate network service to customer and all distribution 
Qualifications :

·  Bachelor degree in Nursing science or related
·  3 to 5 years experience in utilization review, applying Interqual criteria, quality assurance, discharge planning or other cost management programs preferred.
·  Also, experienced in a hospital-based nursing and critical care (ICU, CCU, or Medicine)

Allianz Ayudhya