Job Duties:
- Handle pre-authorization of out-patient, day-patient and in-patient treatment evaluate Medical Necessity and Appropriateness of treatment recommended to insured members by treating doctors in the context of the policy benefits and exclusions.
- Expand Medical Necessity and Appropriateness guidelines and criteria in their applications and usage in the decision-making process and to substantiate by clinical evidence as well as best practice.
- Employ appropriate cost-management measures, including prospective and concurrent Utilisation Reviews, during all treatment episodes of insured members.
- Effective liaison with treating doctors and providers to obtain necessary medical information to conduct utilization management activities.
- Handle medical evacuations in liaison with the emergency assistance vendors as per the established guidelines so as to achieve expected patient outcomes in a most cost-effective manner.
- Provide medical advice and expertise for large loss, complex and contested claims.
- Investigate claims for possible abuse, fraud or medical negligence.
- Use the system effectively to document all aspects of the medical review process including clinical and financial issues and the rationale for the review determination.
- Develop and manage a Network of Preferred Providers.
- Monitor the performance of the Medical Resources team and identify training and development needs to meet competency standards.
- Analyse reports to identify trends and improve claims services and costs.
Requirements:
- Degree in western Medicine is a must, plus Masters in Business Administration with specialization in Healthcare Management is preferred.
- At least 3 years experience in medical insurance industry.
- Proven track record in successfully negotiating with Provider Network members.
- Fluent spoken & written English, Mandarin and Cantonese.
- Good leadership and interpersonal skills and problem solving skills.
- Able to work under tight timelines and high pressure.
Interested Applicants please send your resume (in Word format) together with present and expected salary to Erwin De Smet:
Tel: (852) 2521-5118 ext.824
Email: erwin.desmet@pplesearch.com
** For more job opportunities, please visit our website: www.pplesearch.com **
