Job Description
The job requires assessing case details including members clinical history, benefit structure, clinical information, and coding. Responsibilities involve managing care levels, ensuring appropriate treatment, and coordinating funding decisions. Key duties include communicating with stakeholders, handling escalations, and preparing complex cases for review.
- Assess case in relation to clinical history and benefit structure
- Evaluate clinical information and coding accuracy
- Ensure appropriateness of facility and treating doctor
- Manage risk and appropriateness of treatment
- Communicate effectively with providers and patients
- Engage with patient services and hospital staff
- Handle escalations from providers and internal stakeholders
- Prepare and present complex cases for clinical review
- Conduct trend analysis and propose improvements
- Provide trend analysis and recommendations for management
Qualifications
- Ensures accountability
- Action oriented
- Manages ambiguity
- Attracts top talent
- Business insight
- Collaborates effectively
- Communicates effectively
- Manages complexity
- Handles conflict
- Courage
- Customer focus
- Decision quality
- Develops talent
- Values differences
- Directs work
- Drives engagement
- Financial acumen
- Global perspective
- Cultivates innovation
- Interpersonal savvy
- Builds networks
- Nimble learning
- Organizational savvy
- Persuades
- Plans and aligns
- Being resilient
- Resourcefulness
- Drives results
- Demonstrates self-awareness
- Self-development
- Situational adaptability
- Balances stakeholders
- Strategic mindset
- Builds effective teams
- Tech savvy
- Instils trust
- Drives vision and purpose
- Optimizes work processes
How to Apply
- Apply now
Apply Now ↗
How well do you match?
Get an instant AI match score for this role — free, takes 3 minutes.
Tailor your CV for this role
The concierge rewrites your whole CV and writes a matching cover letter for this job — opens right here, nothing to paste.
Tailor My CV to This Job ✍️