Job Description

Case Management Utilization Review Specialist manages high-cost cases ensuring departmental goals are met, timelines are adhered to, and all compliance measures are taken care of. This report directly reports to Assistant Manager – Case Managent Utilisation Review.

What you do

• Liaise with the Case Management team to develop and implement case management protocols, as well as provide training for the team.
• Identifying and reporting clinical cost drivers to plan Field Control Officers or File Reviews.
• Managing high risk and long stay cases.
• Evaluating Provider & Clinician Abuse to red flag the team . Create a framework for cost controls.
• Coordinating with BD Team & Payers to manage the expectations from Case Management perspective
• Auditing & Signing off the monthly case Management Savings report & sharing with the Assistant Manger.
• Manage Jumbo discounts above 250k AED claim value
• Coordinate with Providers & vendors to get the best cost effective outcome for elective cases
• Ensuring timely closure of disputed cases & cases pending with insurance Payers.
• Achieve a monthly savings target of AED 1M in line with the criteria or methodology defined by the Line Manager and Head of Department.
• Work closely with the Audit and Fraud Waste team to flag providers and clinicians with activities of misrepresentation or malpractice.
• Ensure timely reviews & deicision making  of High costs cases above AED 75,000.
• Assessing cases with multiple admissions and readmission to gauge the provider practice as well as investigate the medical negligence if any.

• AI READINESS Work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics and cloud-based tools, using insights responsibly with our standards of data governance, security and ethical use.

What you bring

• Bachelor’s of Medicine (MBBS);
• 5+ years medical practical experience (reputable insurance provider, broker or a TPA experience a plus).
• Knowledge of overall insurance industry practices is a plus.
• Legally permitted to work in the country of operations.
• Physically fit to carry out duties.
• Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.