Job Description

The Case Manager focuses on the front-end efficiency of the patient journey. You will ensure that specialized consultations, diagnostic procedures, and treatments are medically justified and pre-authorized by insurance providers to prevent financial leakage and treatment delays.

Key Responsibilities:

• Pre-Authorization Management: Review clinical orders (MRIs, specialty medications, minor procedures) to ensure they meet insurance medical necessity criteria before submission.
• Clinical Coding Alignment: Apply your CPC/CCS expertise to verify that ICD-10 and CPT codes accurately reflect the physician’s documentation.
• Denial Prevention: Identify potential “red flag” claims and work with physicians to clarify documentation, reducing the rate of immediate insurance rejections.
• Patient Advocacy: Educate patients on their benefits and coordinate between clinics and payers to expedite approvals for urgent outpatient care.
• Utilization Review: Analyze resource usage to ensure high-turnover clinics are operating efficiently and within payer guidelines.
• Provider Feedback: Meet with department heads to provide updates on changing insurance policies and documentation requirements.

Requirements

• Experience: Minimum 2 years of experience in Case Management, Utilization Review, or Insurance Approvals.
• Certification: Mandatory CPC or CCS certification.
• Clinical Background: Degree in Nursing, Pharmacy, or related Allied Health field preferred.
• Expertise: Deep understanding of DHA outpatient regulations and the e-claims portal.

Summary

Industry:

Healthcare & hospitality