OVERALL PURPOSE OF JOB:
To provide professional and proactive clinical support to clients & team members throughout the claims process. Liaise with members, healthcare providers and other third parties (TPA) to pre-certify treatment, apply appropriate cost containment measures, and co-ordinate local and regional provider direct settlement networks. To provide medical expertise on claims and report worrisome trends.
To provide Network operations support in the applicable regions, in terms of network expansion, arranging direct network access for members at non-contracted providers, maintain provider/TPA relations, discount negotiations and handling emergencies. KEY DUTIES & RESPONSIBILITIES Clinical Services:
Network Management :
- Handle pre-certification of out-patient, day-patient and in-patient treatments by co-ordinating treatment needs with the benefits offered in the insurance plan.
- Liaise with doctors and providers to obtain necessary and accurate medical information within stipulated timeframe.
- Employ prudent cost management measures by coordinating the provision of only medically necessary and appropriate health services.
- Conduct proactive case management of large loss and complex claims with timely notification and approvals to reinsurer and frontiers as per operating procedures.
- Provide medical reviews on nature of medical conditions to support delivery of services, investigate claims for possible abuse, fraud or medical negligence.
- Work closely with operational colleagues to handle all claims related customer queries and complaints.
- Identify worrisome trends and suggest changes to plan terms and conditions, benefits and any relevant policies and practices.
- Carry out Quality audits on timely manner as requested by the line manager.
- Provide clinical support to the global clinical team during their out of office hours.
- Support customer service team by answering calls in their absence.
Compliance and Security
- Work closely with the Chief Medical Officer , APAC network manager and other regional team members towards creating and implementing yearly network related goals/strategies
- Participates in the presentation of the company to potential new providers.
- Maintain provider relationships by regular calls with providers and TPAs via phone and visits.
- Handle Network expansions/Provider additions , region-wise , based on the Business strategy and also via member/client requests
- Assess provider and TPA utilization on a quarterly basis, to identify high cost providers and highly utilised providers
- Conduct discounts negotiations on contracts and also on case-to-case basis.
- Quarterly/Half yearly reconciliation with providers and obtaining sign offs.
- Coordinate claims submission and resubmission from providers
- Manage the AsiaPac network inbox and provider payments inbox in coordination with APAC network manager
- Conduct regular trainings for direct billing providers
- Handling provider /member complaints
- Maintenance of the network list and managing weekly provider updates.
- Maintenance and update of the APAC provider manual
- Take responsibility for establishing and maintaining up-to-date personal awareness of all legislative, regulatory and Company-specific rules, policies and procedures related to performance of the role.
- Ensure consistent compliance with legal, regulatory and Company standards in line with underwriter requirements.
- Pay particular attention to the Company’s Information and Data Security policies when accessing and using all Company systems which may provide access to sensitive information assets, and strive to maintain the highest possible standards of information protection at all times.
- Take individual responsibility for accessing only the systems, records and information required to perform the role. Treat all data contained within those systems in a manner consistent with the Company’s Information and Data Security policies, and in line with the confidentiality clauses provided within the employment contract.
- Ensure any regulatory requirements relevant to the individuals role are met, include certain qualifications and CPD.
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