Sr. Specialist - AAGI A&H Case management - UR 1

Job Summary

Responsible for managing concurrent review processes and case management activities in accordance with medical necessity guidelines and utilization management policies. The role focuses on reviewing ongoing hospitalization cases, ensuring appropriate treatment, and driving cost-effective care throughout the patient journey.

Key Responsibilities

1. Case Review & Management

• Conduct concurrent reviews for pre-authorized admission cases, including long-stay (over 3 days) and complex cases.
• Assess medical reports and treatment plans to ensure clinical appropriateness and adherence to guidelines.
• Monitor high-cost cases and escalate to the medical team when necessary.
• Coordinate with medical consultants for cases that fall outside standard criteria.

2. Cost Management & Optimization

• Verify claim eligibility and manage length of stay to control healthcare costs.
• Recommend alternative treatment pathways that are both clinically appropriate and cost-effective.
• Apply medical necessity guidelines and support claim adjudication processes.

3. Clinical Governance & Compliance

• Evaluate new medical procedures, drugs, and technologies for safety and appropriateness.
• Detect and escalate potential fraud, abuse, or suspicious claims to the Clinical Governance team.
• Ensure compliance with Thai Medical Practice Guidelines and insurance policies.

4. Coding & Reporting

• Perform medical coding (ICD) related to procedures and claims processing.
• Prepare cost-saving reports and monthly productivity reports for concurrent review activities.

Must Have

• Bachelor’s degree in nursing science
• Minimum 5 years’ experience in clinical nursing (UR) and medical management from insurance company
• Minimum 3 years of clinical nursing experience in critical care units (ER, ICU, OR) is highly preferred.

Nice to Have

• Experience in insurance, healthcare, or related industries.
• Knowledge of utilization management, case management, and medical claims processes.
• Familiarity with ICD-10 coding and healthcare regulations.
• Strong understanding of medical and insurance terminology (including health, dental, maternity, and mental health).
• Excellent communication and interpersonal skills, with the ability to work in a fast-paced environment.
• Any AI-future skills e.g., ChatGPT, or CoPilot365, will be advantage.