Tpa Medical Insurance jobs

1. JOB PURPOSE

The Case Manager plays a critical role in evaluating, coordinating, and facilitating appropriate treatment plans in collaboration with healthcare providers, payers, and internal teams, while ensuring compliance with policy terms and clinical guidelines. To ensure the delivery of high-quality, cost-effective inpatient care by managing complex and high-cost medical cases.

2. RESPONSIBILITIES AND DUTIES

• Conduct thorough clinical, policy, and coding assessments of complex inpatient cases.
• Identify and manage eligible cases such as high-cost admissions, prolonged hospital stays, complications, and disputed claims.
• Liaise with treating physicians, hospital insurance departments, and payers to ensure appropriate care and cost containment.
• Perform on-site hospital visits when necessary to review medical records, discuss treatment plans, and negotiate discounts.
• Ensure accurate DRG coding and severity level classification in line with UAE and international guidelines.
• Coordinate second medical opinions and referrals to low-cost or home-country facilities when appropriate.
• Draft detailed case summaries and recommendations for payer approval.
• Maintain accurate documentation and reporting of all case management activities.
• Collaborate with internal teams to resolve ambiguities and ensure consistent decision-making.
• Monitor and report cost savings achieved through negotiated discounts, DRG adjustments, and alternative treatment plans.

3. KNOWLEDGE, SKILLS, AND EXPERIENCE

• Bachelor’s degree in medicine MBBS/ MD (mandatory).
• Certification in Health Insurance, Coding, Audit or Case Management is an advantage.
• Minimum 3–5 years of experience in Health Insurance Sector.
• Strong knowledge of DRG coding, UAE billing guidelines, and insurance policy interpretation.

Job Types: Full-time, Permanent

Pay: AED13,000.00 - AED14,000.00 per month

Work Location: In person