Job Description

Job Description

To support the case management function by evaluating medical cases, assisting in care coordination, and ensuring adherence to Daman’s medical policies and guidelines. The role involves collecting and analyzing case-related data, reporting findings, and facilitating effective communication between stakeholders to optimize patient outcomes while maintaining compliance with healthcare regulations.

Responsibilities

Core Responsibilities:
•    Obtain and review all necessary clinical information to ensure appropriate utilization of resources for medical service approvals.
•    Communicate and coordinate effectively with healthcare providers to minimize fragmentation in patient care. 
•    Assist members in navigating the healthcare system to facilitate high-quality and timely medical outcomes.
•    Research and gather medical and financial information to support case evaluations and cost assessments.
•    Document all relevant patient care information in the recording system to ensure accessibility for the case management team.
•    Issue and modify authorizations as required to facilitate the provision of necessary medical services
•    Evaluate patient health needs and assess the availability of necessary resources to provide appropriate medical support. 
•    Conduct concurrent medical record reviews using specific indicators and criteria to monitor patient progress and update care plans as necessary.
•    Report emerging trends in provider behaviour to relevant stakeholders for further investigation and corrective actions.
•    Verify compliance with internal policies and external healthcare regulations when processing medical service approvals.
•    Meet with internal teams to ensure seamless coordination and resolution of case-related issues.
•    Summarize case details for reporting purposes, ensuring clarity and accuracy.
•    Adapt a comprehensive care coordination approach in collaboration with primary care physicians/providers to optimize patient health outcomes.

Quality & Excellence Management:
•    Observe industry best practices and healthcare regulations to maintain high-quality case management standards.
•    Maintain flexibility to work on provider premises if required to enhance service delivery.
•    Monitor medical service utilization to identify trends and recommend improvements in authorization processes.
•    Review patient care documentation and provider interactions to ensure service quality and adherence to guidelines.
 

Qualifications

Preferred Educational Qualifications and Professional Certifications
•    Bachelor’s Degree in Healthcare Management, Nursing, Medicine, or a related field.
•    Master’s Degree in Healthcare Administration, Public Health, or a related field is preferred. 
•    Professional certifications such as Case Management Certification (CCM), Certified Professional in Healthcare Management (CPHM), or equivalent is advantageous.
 

Experience    
•    A minimum of 0-2 years of experience in case management, healthcare operations, or medical insurance, with expertise in reviewing medical cases, coordinating healthcare services, and collaborating with healthcare providers.