Clinical Case Manager
The Clinical Case Manager will report to the Clinical Service 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 Clinical Case Manager 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 BGAIM 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 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
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 86,000 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's Strategic Framework
Our strategy has three pillars: Customers, People, Performance. It puts our customers front and centre in the context of today’s digital age. As a service organisation, everything we do for our customers relies on our people and partners, so being a place where people love to work is critical to our success. This, combined with disciplined risk and capital management, is how we will deliver strong and sustainable performance. We are looking for individuals who share in our values and this strategy, and are capable of delivering outstanding results for the business.
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.