Duties & Responsibilities:

• Implement strategies in collaboration with the healthcare team to reduce length of stay (LOS) and resource utilization, never compromising quality or outcomes.
• Ensure patients are in the appropriate level of care according to evidenced based, physician approved criteria and standards and prescribed plan of care.
• Ensure pre-authorizations for services are obtained in a timely manner.
• Facilitate the discharge planning process to ensure patient throughput by collaborating with the healthcare team.
• Report to Care Management leadership, the identification avoidable days and other Care Management measures including, but not limited, readmissions, saved days, core measure monitoring, interventions, and delays, to ensure data is accurately collected.
• Prioritize patient’s need for Care Management services based on: target/high volume Diagnosis-Related
• Group, high cost, outlier, LOS, frequent inpatient admissions, unplanned readmission or significant variance.
• Identify risk factors for potential crisis intervention needs related to clinical diagnosis, prognosis and/or patient/family dynamics.
• Identify and report ethical situations to manager/medical director for resolution.
• Ensure the multidisciplinary discharge plan is consistent with the patient’s clinical course, continuing care needs and covered services. Evaluate on an ongoing basis the patient’s status and progress toward reaching goals set forth in the plan of care.
• Collaborates with patients, families and other members of the healthcare team to facilitate care coordination.
• Handle all patient care concerns in a prompt and courteous manner; assess and direct to appropriate person to deal with concerns as needed.
• Act as the liaison for insurance companies and other corporate clients and performing care management functions to ensure accurate and timely dissemination of information to insurances companies

Qualifications &Legal Requirements

• Degree/ Diploma in Nursing or Clinical Medicine.
• Previous experience in an Insurance company / Extensive understanding of the concepts of health insurance.
• Good interpersonal, communication and negotiation skills.
• Knowledge of computers and MS office operating programs.
• Proven ability to build strong client relationships and maintain excellent customer focus.

Key Performance Indicators

• Ensure pre-authorizations for services are obtained within 12hrs.
• Identify risk factors for potential crisis intervention needs related to clinical diagnosis, prognosis and/or patient/family dynamics and report them immediately they are identified.
• Vetting and confirming validity of all medical reports & diagnostics prescribed in the hospital on a daily basis.
• Share a weekly activity report on care trends and recommendations (Reporting Errors, Medication Errors and Billing Errors etc.)
• Conduct training on preauthorization’s to Doctors, Nurses and Ward coordinators. At least once a month.
• Ensure all corporates get their list of admitted patients and necessary bills via email by 9am every morning.
• Ensure all hospital specialists are on all major insurance panels.