Case Management Consultant
The Case Management Consultant will report to the Clinical Audit manager with the primary goal of individual case management of medical cases as specified by the business to ensure quality care with special focus on balancing financial savings. This role ensures that all parties (broker, company, provider, service partner, colleagues) involved are kept up to date on the progress of authorisation and case details. The Case Management Advisor will have an integral role in the current case management process, as well as the claims audit and on-site case review.
- Investigate, and respond to enquiries for complex medical authorisations and high value within certain threshold and criteria claims from members, providers, group secretaries, service partners and intermediaries in the appropriate method, in line with Bupa Global policy and management style.
- Pro-actively contact members, providers, service partners and intermediaries via telephone, email, fax and letter to advise on decision of request and fully explain benefit entitlement to all parties.
- Ensure the correct interpretation of Bupa Global’s policy and rules, using the correct compatible combinations of codes for accurate processing of data, in accordance with our service standards and customer expectations
- Liaise with Global clinical staff to interpret condition and treatment to the rules and regulations of Bupa Global
- Liaise with all areas of the business to assist with resolving enquiries, such as claims eligibility, coverage and alternative treatments.
- Works with audit and pre-authorization teams to identify and investigate any fraud or abuse.
- Preparing case reports for each investigation performed. Keeping record of daily activity for monthly reporting.
- Identify opportunities to reduce future claim expense for Bupa Global and to pro-actively provide relevant information to Risk management department
- Proactively negotiate medical costs and/or medical treatment to achieve either reduced cost to the business or most appropriate treatment for member.
- Develop and maintain an up to date and accurate knowledge of appropriate Bupa products, policies and initiatives in order to ensure that all queries are answered accurately.
- Support Bupa BG AIM medical teams to provide provider/specialist recommendation, estimate medical costs helping make appointment, support case management, etc. Achieve departmental and individual KPIs
- Take responsibility for the logging of written queries and complaints on the customer database, ensuring it is up to date and as accurate as possible.
- To comply with and take into account any requirements from the local regulators and/or any applicable local regulatory requirements
- Handling complaints and investigating the root cause to provide clear goal oriented solutions
The Ideal Candidate
- Good interpersonal skills.
- Ability to work with a team
- Respects diversity and embraces cultural differences.
- Willing to work outdoor with possible multiple visits per day.
- Excellent record keeping and reporting skills, with ability to deliver reporting requirements in due time.
- Understands the business commitment to meet deadlines and Turn-around times.
- Good judgement and ability to prioritise workflow according to business needs.
Qualifications and requirements
- Excellent medical background with practical medical experience.
- MBBS or nursing school degree.
- Previous UAE medical insurance experience is mandatory.
- Superior customer service and negotiation skills.
- Knowledge of clinical billing and coding is a must – Certified coding degree is a plus.
- Basic knowledge of DRG system.
- Excellent knowledge of Microsoft Word® and Microsoft Excel® is a must.
About the Company
Bupa’s purpose is longer, healthier, happier lives.
As a leading global health and care company, we offer health insurance, medical subscription and other health and care funding products; we run care homes, retirement and care villages, primary care, diagnostic and wellness centres, hospitals and dental clinics. We also provide workplace health services, home healthcare, health assessments and long-term condition management services. We have 32M customers globally. With no shareholders, we invest our profits to provide more and better healthcare and fulfil our purpose. We employ 84,000 people, principally in the UK, Australia, Spain, Poland, New Zealand and Chile, as well as Saudi Arabia, Hong Kong, India, and the USA.
We have grown significantly, particularly through 2013 to 2015, when we accelerated execution of our strategic vision. We are similar in revenue and profit to Marks & Spencer, and larger than Heinz in revenue. Because Bupa does not have shareholders it does not have a listing, but if it did it would be in the FTSE 100. Bupa is not a mutual or a charity but a company limited by guarantee that seeks to maximise its profits in order to fulfil its purpose. With customers in virtually every country in the world and 70% of its revenues now generated outside the UK, Bupa is a truly international organisation.
Bupa believes that the growth and performance of our leaders and our people is the single biggest pathway to fulfilling our purpose (longer, healthier, happier lives) and delivering Bupa's strategic priorities. We have a leadership framework called “Bupa Leaders Are” which sets out what great leadership looks like at Bupa. Leaders are called upon to grow themselves, to grow others, to grow the business, and fulfil our purpose: longer, healthier, happier, lives. We are looking for individuals who are capable of delivering extraordinary business outcomes.
Bupa’s International Markets (IM) unit has 16 million customers across all continents around the world. It manages a portfolio of businesses, including a large international health insurance, travel insurance and medical assistance business called Bupa Global, as well as established domestic health insurance businesses in Hong Kong and Brazil, two associate health insurance companies in Saudi Arabia (34.25% Bupa ownership) and India (49% Bupa ownership), and Hong Kong’s largest private clinic network.
Bupa Global provides products and services worldwide to people who want access to premium health and care at home or as they study, live, travel or work abroad. We provide international health insurance, travel insurance and medical assistance to individuals, small businesses and global corporate customers all around the world.
Bupa Global has over 1,800 employees and has offices in London and Brighton (UK), Miami (USA), Copenhagen (Denmark), Hong Kong (Greater China), and Dubai (UAE), as well as in Egypt, Mexico, the Dominican Republic, Bolivia, Panama, Guatemala and Ecuador. Bupa Global is currently organised around five regional hubs: Bupa Global Africa, India & Middle East; Bupa Global Greater China; Bupa Global Latin America; Bupa Global North America and Bupa Global Europe.
Timescales for reviewing applications will differ between regions, but you will always receive a response to your application. The recruitment process itself will vary per role and region, but you will be updated along the way via phone and email (so please look out for these!). To view what stage of the process your application is currently at, you can also log in and view your dashboard.
If you are invited to an interview, a member of the resourcing team will be able to advise you on what to expect. This will vary in region, but will likely include an initial phone or digital interview, followed by one or more of the following depending on the role: Core capability interview; Technical/function specific interview; Online profiling assessment; Presentation, written task, role play; Assessment centre.
If your application is successful and you’re invited to join the team, the resourcing team will guide you through your on boarding journey.
Should you require any reasonable adjustments to be made or facilities provided to enable you to attend an interview, please do not hesitate to contact us prior to the interview at email@example.com, so we can make adjustments accordingly.