Medical Case Manager

Medical Case Manager - Detalhes da Vaga. ● The Case Manager will ensure that members receive appropriate care by proactively working with providers, estimating the future cost of care, and monitoring the members medical records. ● The overall goal of the position is to enhance the quality of patient management and satisfaction and to promote continuity of care and cost effectiveness through the functions of case management, utilization review and management, and discharge planning. ●ESSENTIAL JOB DUTIES AND RESPONSIBILITIESReview, monitor and proactively assess all cases with a focus on those cases with a high-cost potential (daily and ongoing). ●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. ●Acts as member advocate by investigating, documenting, reporting, and escalating adverse occurrences/situations to management. ●Prepares, coordinates, and facilitates a weekly Case Management Meeting. ●Acts as a key participant in the claim review meetings (i. ●E. ● Claims Review Committee and Big Claims Committee) and provides updates on high-cost cases. ●Manages care of members who require medical care for an acute, chronic, or catastrophic event using disease management parameters and quality criteria. ●Liaise and coordinate with medical professionals, administrators of healthcare providers, and members to ensure the cost-effectiveness and appropriateness of the treatment. ●Work and understand the scope of the pre-authorization and case assessment processes in compliance with the policy''s terms and conditions. ●Maintain timely and thorough documentation of all interactions with healthcare professionals about member care to facilitate efficient claims processing. ●Developing and implementing individualized care plans and discharge planning for patients, considering their medical conditions, treatment goals, and resources available. ●Perform proper and detailed investigations of cases to ensure correct application of benefits. ●Maintain an updated case management report of high-cost cases. ●Work closely with the departments of Provider Services, Claims, and Patient Services. ●Work with the Precertification Medical Team and analyze if care received by our members was appropriate for the diagnosis and condition of the insured. ●Support the medical coordinator in reviewing medical records related to claims assigned by Claim Adjudicators through our document imaging application (Docuphase). ●Assist Precertification with the review of medical records for acute cases handled by the Medical Coordinators. ●Participate and support On-Call services. ●Perform other duties as designated by the Senior Manager of Case Management Dpt. ●DESIRED MINIMUM QUALIFICATIONSStrong knowledge of medical conditions and correlations between medical conditions and potential medical expenditures. ●Strong knowledge of managed care policies and principles. ●Ability to measure risk and potential impact of cases and claims for the business. ●Strong analytical abilities and attention to detail. ●Able to work independently with strong initiative and minimal supervision. ●Strong commitment to service, quality, and care of members. ●Ability to maintain a balanced workload and prioritize accordingly. ●Bilingual Portuguese English (must be fluent in English) - speak, read and write. ●Spanish fluency could be a plus. ●EDUCATION AND EXPERIENCEMedical Physician with a minimum of 5 years of related healthcare experience. ●3+ years of experience in healthcare working in medical coordination, case management and/or medical audit. ●NECESSARY KNOWLEDGEFamiliar with health insurance principles and guidelines. ●Seniority levelAssociateEmployment typeContractJob functionAdministrative and Customer ServiceIndustriesInsurance#J-18808-Ljbffr. Requisitos para participar do processo. ● . O que oferecemos.