Opportunity Description
Case Management Utilization Review Specialist manages high-cost cases ensuring departmental goals are met, timelines are adhered to, and all compliance measures are taken care of. This report directly reports to Assistant Manager – Case Management Utilization Review.
Responsibilities
- Liaise with the Case Management team to develop and implement case management protocols, as well as provide training for the team.
- Identifying and reporting clinical cost drivers to plan Field Control Officers or File Reviews.
- Managing high risk and long stay cases.
- Evaluating Provider & Clinician Abuse to red flag the team and create a framework for cost controls.
- Coordinating with BD Team & Payers to manage the expectations from Case Management perspective.
- Auditing & signing off the monthly case management savings report and sharing with the Assistant Manager.
- Manage jumbo discounts above 250k AED claim value.
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