Job Description

The Case Management Utilization Review Lead is responsible for in managing the High-cost cases while ensuring that departmental goals, timeline of activities, and compliance measures are met
What you do

• Performing complete file review of high cost claims with regards to the multidisciplinary notes, TPR charts, physician order's notes, lab reports, radiology reports, drug chart sheets, consultation notes, nursing notes, progress notes, etc.

• Field hospital deployment or File Audit to be performed when required (Non- Physical or Physical [Provider Visit]) to capture hospital acquired infections, mismanagement, iatrogenic injuries, etc.

• Requesting any medical documentation or finding any missing document which is essential in decision making.

• Performing review of DRG Severity of Illness (SOI) in line with revision of CPT codes / ICD codes, which are being up-coded by the provider - if required discussion with the treating doctor and the medical coders.

• Performing utilization review for DRG cases and FFS cases with regards to and not limited to final bill review + consumables mark ups + non covered item/services + overutilization of services.

• Performing review of claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA,DOH/HAAD,MOH).

• Pre-authorization and maintaining required out-put of high cost claims with detailed insight of claim on day to day basis.

• Adhering to the case management and cost containment protocols for elective high cost cases and medical management cases.

• Referring cases for second opinion when deemed necessary to confirm the best mode of management - also for cost containment to lesser Negotiating factor (NF) facilities within the member's network or option for home country treatment.

• Adjudicates High Cost claims at submission level for settlement between the insurer and health care provider as per policy terms and conditions.

• Adjudicates High cost claims at precertification level, authorize decision on the claim within policy terms and conditions.

• Continuously work to identify possible procedure inconsistencies; develop, recommend and implement improvements.

• Provide support to Medical Claims Officers to close all escalated claims queries within the agreed turn-around time.

• Achieving a monthly savings target of AED 800,000 in line with the criteria or methodology defined by the Line Manager and Head of Department.

What you bring

• Bachelor's of Medicine (MBBS);

• 3+ years medical practical experience (reputable insurance provider, broker or a TPA experience a plus).

• Knowledge of overall insurance industry practices is a plus.

• Legally permitted to work in the country of operations.

• Physically fit to carry out duties.

• Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.

What we offer
Our employees play an integral part in our success as a business. We appreciate that each of our employees is unique and has unique needs and ambitions, and we enjoy being a part of their journey.
We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is a key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance.
87743 | Customer Services & Claims | Professional | Non-Executive | Allianz Partners | Full-Time | Permanent
Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us.
At Allianz, we stand for unity: we believe that a united world is a more prosperous world, and we are dedicated to consistently advocating for equal opportunities for all. And the foundation for this is our inclusive workplace, where people and performance both matter, and nurtures a culture grounded in integrity, fairness, inclusion and trust.
We therefore welcome applications regardless of ethnicity or cultural background, age, gender, nationality, religion, social class, disability or sexual orientation, or any other characteristics protected under applicable local laws and regulations.
Great to have you on board. Let's care for tomorrow.
Note: Having different strengths, experiences, perspectives and approaches is an integral part of Allianz' company culture. One means to achieve this is a regular rotation of Allianz Executive employees across functions, Allianz entities and geographies. Therefore, the company expects from its employees a general openness and a high motivation to regularly change positions and collect experiences across Allianz Group.

Skills Required