Job Purpose

To review, assess and evaluate the medical care provided to patients to ensure appropriateness, cost-effectiveness, and adherence to clinical standards and policy guidelines. The role ensures that patient care meets the expected quality and complies with payers or regulatory requirements.

Main Duties and Responsibilities

Ensure discharge TAT of less than 2 hours by assessing all patient medical records, treatment notes, and diagnostics results realtime to verify the necessity and appropriateness of care.

Review inpatient and outpatient care and documentation for clinical accuracy and justification including diagnosis and insurance exclusions.

Ensure treatments procedures comply with clinical guidelines.

Evaluate insurance claims for completeness and correctness before approval.

In liaison with care manager, liaise with insurance companies and other payers on clinical queries.

Daily ward rounds to monitor standards of care delivered across different departments.

Participating in clinical audits, hospital surgical package review meetings as well as contributing to overall care improvement programs and initiatives.

Work with clinicians, billing teams, and claim units to align clinical and financial processes

Minimum Requirements/ Qualifications

Diploma in Nursing from a recognized Institution.

Valid practicing license.

At least 2 years’ experience as a general nurse and 1 year in a similar role.

Insurance training is an added advantage.

Familiarity with Medical coding. (ICD-10, CPT)

Key Job Requirements

Excellent communication and customer service skills.

Good interpersonal skills and a team player.

Flexible and can work under pressure with minimum supervision.

Desire for personal development, improvement, and learning.