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
- 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.
About the Company
We are a health insurer and provider. With no shareholders, our customers are our focus. We reinvest profits into providing more and better healthcare for the benefit of current and future customers.
Bupa’s purpose is longer, healthier, happier lives and making a better world.
Here you’ll be welcomed. We champion diversity and we understand the importance of our people representing the communities and customers we serve. You’ll find an inclusive environment where you can be yourself and where everyone is driven by the same purpose – helping people live longer, healthier, happier lives.
Bupa Global is the international health insurance division of Bupa. We provide customers who want premium international coverage with products and services to access the healthcare they need anytime, anywhere in the world, whether at home or when studying, living, travelling or working abroad.
Bupa Global has offices around the world including London and Brighton (UK), Miami (USA), Copenhagen (Denmark), Dubai (UAE, in partnership with OIC), and Hong Kong (China) as well as regional offices in mainland China, Singapore, Egypt, Mexico, the Dominican Republic, Bolivia, Brazil, Panama, Guatemala and Ecuador.
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.