Medical Evaluator (Case Manager)

Description

JOB PURPOSE & OBJECTIVES: The case manager will work directly with the Senior Case Manager and Director of Medical Services to support the management of members who require medical care (acute, chronic or catastrophic events). Will ensure members receive appropriate care, proactive planning for long term resource allocation, estimating future cost of care by visiting patients if location allows or by working closely with providers and monitoring the medical records. The case manager will also assist with cost containment strategies to maintain medical loss ratio to a minimum by performing interventions/actions that can be reflected into best services towards our clients and savings towards the company (aligned as per corporate strategies and department goals).

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES • Manages care of members who require medical care of an acute, chronic or catastrophic event using disease management parameters, quality criteria, and clinical care guidelines. • Liaise and coordinate with medical professionals, administrators of healthcare providers and customers to ensure the cost-effectiveness and appropriateness of treatment • Work and understand the scope of pre-authorization and case assessment in compliance with the terms and conditions of the policy. • Maintain timely and thorough documentation of all interactions with any healthcare professionals pertaining to patient care to ensure it is readily available for efficient claims processing. • Continuous review, monitoring and proactive assessment of all cases deemed to be sensitive. • Proper and detailed investigation of cases to identify correct use of benefits and billing guidelines. • Maintain an updated case management report in internal repository of high cost cases. • Be a key participant in the Transplant Committee and provide updates on these cases periodically. • Responsible for preparation and presentation of the high cost/catastrophic cases assigned in the Claims review committed and/or Big Claims Committee meetings on a weekly/monthly basis. Revised 2/2018 • Assist the medical team by obtaining medical records, coordinating discharge planning (home health care, DME, inpatient rehab), guiding the clients/agents to our preferred providers based on specific needs. • Responsible for preparing and leading the weekly CM meeting to discuss currently admitted and ongoing high risk cases with the medical coordinators including weekly follow ups and actions as required. • Assist and train medical coordinators to provide proper follow up in high cost cases. • Ability to successfully prioritize and complete a multitude of different tasks. • Perform other duties as designated by the Senior Case Manager and Medical Director.

Qualifications

DESIRED MINIMUM QUALIFICATIONS • Strong knowledge of medical conditions and understanding of correlations between medical conditions and potential medical expenses. • Strong knowledge of managed care policies and principles of the health insurance industry. • Ability to measure risk and project costs related to ongoing medical treatment. • Strong analytical abilities and attention to detail. • Able to work independently with strong initiative and minimal supervision. • Strong commitment to delivering and maintain a high level of service and quality. • Ability to maintain a balanced workload and knowing how to prioritize tasks accordingly. • Bilingual – English/Spanish – Must be able to speak, read, write and perform all business functions (negotiate, communicate effectively internally and externally) in both languages fluently. • Knowledge on Microsoft office suite (Excel, Word, SharePoint, and Outlook) is required.

EDUCATION AND EXPERIENCE • Minimum of 3 years’ experience in the medical field, working in medical coordination and case management is required. • Knowledge of ICD-10, CPT, HCPS, DRG’s is required. • Experience working in processing health insurance claims/billing and knowledge of provider contracts is a plus. • Strong negotiating skills desired. • Experience working in the International Health Insurance Market is preferred. • Licensed Vocational Nurse (LVN) or foreign medical graduate (FMG) with a minimum of 5 years of experience is desired.