Medical Case Manager

Best Doctors Insurance; São Paulo; Presencial; BRL 60.000 - 100.000; Tempo integral

Resumo da oferta

Uma empresa inovadora no setor de seguros busca um Gerente de Casos para fornecer suporte e expertise na gestão de cuidados médicos. O profissional será responsável por avaliar, planejar e implementar cuidados para membros que enfrentam eventos médicos agudos, crônicos ou catastróficos. Com um foco na qualidade do atendimento e na satisfação do paciente, essa posição envolve a coordenação com profissionais de saúde e a documentação meticulosa das interações. Se você é apaixonado por saúde e deseja fazer a diferença na vida das pessoas, essa pode ser a oportunidade perfeita para você.

Qualificações

• Médico com forte conhecimento em condições médicas e políticas de cuidados gerenciados.
• Experiência em coordenação médica e gestão de casos é essencial.

Responsabilidades

• Avaliar e monitorar casos de alto custo com foco em cuidados adequados.
• Desenvolver planos de cuidado individualizados e facilitar reuniões de gestão de casos.

Conhecimentos

Conhecimento em condições médicas

Análise de risco

Fluência em inglês

Atenção aos detalhes

Iniciativa e trabalho independente

Formação académica

Médico com 5 anos de experiência em saúde

Experiência em coordenação médica ou gestão de casos

Ferramentas

Docuphase

Descrição da oferta de emprego

The Case Manager will work directly with the Senior Manager of Case Management to provide ongoing support and expertise through the comprehensive assessment, planning, implementation, and overall evaluation of those members who require medical care due to acute, chronic, or catastrophic events. The Case Manager will ensure that members receive appropriate care by proactively working with providers, estimating the future cost of care, and monitoring the members’ medical records. The overall goal of the position is to enhance the quality of patient management and satisfaction and to promote continuity of care and cost effectiveness through the functions of case management, utilization review and management, and discharge planning.

ESSENTIAL JOB DUTIES AND RESPONSIBILITIES

1. Review, monitor and proactively assess all cases with a focus on those cases with a high-cost potential (daily and ongoing).
2. Assist and train Medical Coordinators to provide proper follow-up in high-cost cases.
3. Ability to successfully prioritize and complete a multitude of different tasks.
4. Acts as member advocate by investigating, documenting, reporting, and escalating adverse occurrences/situations to management.
5. Prepares, coordinates, and facilitates a weekly Case Management Meeting.
6. Acts as a key participant in the claim review meetings (i.e. Claims Review Committee and Big Claims Committee) and provides updates on high-cost cases.
7. Manages care of members who require medical care for an acute, chronic, or catastrophic event using disease management parameters and quality criteria.
8. Liaise and coordinate with medical professionals, administrators of healthcare providers, and members to ensure the cost-effectiveness and appropriateness of the treatment.
9. Work and understand the scope of the pre-authorization and case assessment processes in compliance with the policy's terms and conditions.
10. Maintain timely and thorough documentation of all interactions with healthcare professionals about member care to facilitate efficient claims processing.
11. Developing and implementing individualized care plans and discharge planning for patients, considering their medical conditions, treatment goals, and resources available.
12. Perform proper and detailed investigations of cases to ensure correct application of benefits.
13. Maintain an updated case management report of high-cost cases.
14. Work closely with the departments of Provider Services, Claims, and Patient Services.
15. Work with the Precertification Medical Team and analyze if care received by our members was appropriate for the diagnosis and condition of the insured.
16. Support the medical coordinator in reviewing medical records related to claims assigned by Claim Adjudicators through our document imaging application (Docuphase).
17. Assist Precertification with the review of medical records for acute cases handled by the Medical Coordinators.
18. Participate and support On-Call services.
19. Perform other duties as designated by the Senior Manager of Case Management Dpt.

DESIRED MINIMUM QUALIFICATIONS

1. Strong knowledge of medical conditions and correlations between medical conditions and potential medical expenditures.
2. Strong knowledge of managed care policies and principles.
3. Ability to measure risk and potential impact of cases and claims for the business.
4. Strong analytical abilities and attention to detail.
5. Able to work independently with strong initiative and minimal supervision.
6. Strong commitment to service, quality, and care of members.
7. Ability to maintain a balanced workload and prioritize accordingly.
8. Bilingual Portuguese – English (must be fluent in English) - speak, read and write.
9. Spanish fluency could be a plus.

EDUCATION AND EXPERIENCE

1. Medical Physician with a minimum of 5 years of related healthcare experience.
2. 3+ years of experience in healthcare working in medical coordination, case management and/or medical audit.

NECESSARY KNOWLEDGE

Familiar with health insurance principles and guidelines.

Seniority level

Associate

Employment type

Contract

Job function

Administrative and Customer Service

Industries

Insurance