Our preauth department is looking for a case manager who will be responsible for improving clinical outcomes,increase patient satisfaction and promote cost effectiveness.

Key Tasks

Manage Pre Auth cases:

•         Assist to determine admission requirements.

•         Assist to provide the pre-auth team with valid recommendations for pre-auth request

•         Coordinate and provide care that is safe, timely, effective, efficient, equitable and client centred

•         Manage declined cases

•         Review case progress and determine case closure

•         Assess treatment needs

•         Monitor and evaluate treatment plans and progress

•         Facilitate hospital admissions and LMS dispatch

•         Help members make informed decisions about treatment options

•         Promote quality and cost-effective interventions and outcomes

•         Adhere to professional standards as outlined by protocol, rules and regulations.

•         Maintain constant contact with treatment DR/Hospital

•         Educate members and medical staff of limits of benefits

•         Respond to quires and complaints within SLA (24 Hours)

•         Maintain high standard of product knowledge

•         Monitor and recommend training interventions within pre auth department

•         Hospital case financial reconciliation accuracy

•         Clinical intervention documentation completeness - clinical notes and doctor's orders

•         Manage Error ratio in clinical reporting

•         Manage High-cost case escalation accuracy

Perform administrative duties:

•         Review medical records to identify medical issues

•         Complete and present case review preparations

•         Compile and submit periodic reports

Clinical Bill Auditing

·       Assessing of ICU/HIC, continuation cases, high-cost claims and claims exceeding LOS of 5 days

• Assess claim based on pre-authorisation and case management agreements
•     Check for over billing and/or over servicing and incorrect coding, or charges

·       Adjudicate claims and resolve claim disputes with service providers and obtain applicable amended accounts.

• Submit amended accounts to Claims Department for payment

·    Exclude possible non-disclosure of pre-existing conditions

·       Maintain SLA to action and provide feedback to OTRS tickets within 48 hours

·       Keep abreast of amendments to policy rules, benefit options, legislation, protocols, processes, and systems