Clinical Case Manager

MSH Americas - Diot-Siaci Group; Toronto; Hybrid; CAD 100,000 - 125,000; Full time

Job summary

An innovative firm is seeking a Clinical Case Manager to bridge the gap between Precertification and Clinical Advisory roles. This hybrid position involves providing clinical support to various teams, reviewing precertification requests, and ensuring adherence to medical guidelines. The ideal candidate will have a strong background in the insurance or medical field, excellent analytical skills, and a commitment to superior customer service. Join a supportive environment that values diversity, promotes inclusivity, and offers opportunities for professional growth and skill development. If you're ready to make a significant impact in a dynamic role, this is the opportunity for you.

Benefits

Employee assistance program

Wellness account

RRSP matching

Generous sick and flex days

Opportunities for skill growth

Supportive leadership

Diversity and inclusivity initiatives

Qualifications

• 3-5 years of relevant business experience required.
• Experience in insurance industry/medical field is essential.

Responsibilities

• Review precertification requests and provide expert medical opinions.
• Manage major cases and participate in new projects as needed.

Skills

Attention to Detail

Customer Service

Analytical Skills

Multi-tasking

Diplomatic Communication

Education

College/University diploma/degree

Equivalent work experience

Tools

Microsoft Office

V9

Intraqual

Job description

The Clinical Case Manager serves as a hybrid role between a Precertification Administrator and a Clinical Advisor. This position provides clinical support to the Precertification, Claims, and Customer Care Teams in Calgary or other offices as needed.

In this role, you’ll get to experience:

Clinical Responsibilities:

1. Review precertification requests received via e-mail, medical opinion tool, request/complaint workflow tool, or verbally, providing expert medical opinions regarding medical necessity, length of stay, and reasonable and customary charges for medical services.
2. Offer medical opinions for the Claims Team as required.
3. Conduct second reviews and approve large claims as per current procedures.
4. Perform clinical reviews and follow-ups on Disability Claims (Weekly Indemnity).
5. Actively participate in managing major cases, including establishing reserves and appropriate follow-up.
6. Provide training to TPA on medical topics relevant to claims adjudication.
7. Participate in new projects as needed.
8. Take an active role in the Precertification Department, handling all duties related to Authorizations.
9. Review pending PEC requests and preapprovals in the main Precertification e-mail box or Intraqual. Prioritize and process all requests for the North/South American zone and emergency requests for other zones, including those received via the after-hours phone.
10. Process precertification requests (PECs, LOGs, IOs) on V9 as appropriate.
11. Receive requests for precertification by phone, e-mail, or Intraqual workflow.
12. Check the eligibility of the insured.
13. Confirm eligibility of expenses as per policy requirements and direct-payment guidelines.
14. Issue Precertification Agreements on V9.
15. Leave required notes in the appropriate section of V9 insureds’ records.
16. Inform and respond to insured members’ inquiries about procedures to be followed or the status of their pre-certification file via telephone, fax, e-mail, or Intraqual workflow.

Performance Measures:

1. Accuracy and quality of medical information provided.
2. Adherence to privacy laws and guidelines.
3. Maintenance of medical confidentiality.
4. Meeting established performance measures for precertification-related tasks.

What you bring:

1. College/University diploma/degree or equivalent work experience.
2. 3-5 years of relevant business experience.
3. Experience as a Claim Administrator.
4. Previous experience in the insurance industry/medical field.
5. Intermediate knowledge of Microsoft Office applications.
6. Proficiency with the internet and email.
7. Familiarity with specialized medical internet sites.

What do you need to succeed?

1. Advanced knowledge of medical/dental terminology (asset).
2. Proficient in English; French (asset).
3. Strong attention to detail.
4. Multi-tasking and adaptability.
5. Excellent organizational and prioritization skills.
6. Superior customer service abilities.
7. Effective team collaboration.
8. Proficient in interpreting health insurance policies/contracts.
9. Strong analytical skills.
10. Proactive approach.
11. Empathy and client reassurance.
12. Diplomatic communication.

What’s in it for you:

1. Hybrid work environment.
2. Employee assistance program.
3. Wellness account.
4. RRSP matching.
5. Generous amount of sick and flex days.
6. Opportunities to learn new skills, grow, and move into different roles.
7. A work environment that embraces diversity and promotes inclusivity.
8. Supportive leadership prioritizes your success and cares about your well-being.
9. A growth trajectory designed to expand vertically and horizontally, providing opportunities to pursue your passions and acquire new skills.

MSH is an Equal Opportunity Employer.

MSH Americas is an equal opportunity employer and does not discriminate against any employee or applicant for employment based on race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other protected status under applicable law. We encourage and welcome applicants from all backgrounds to apply for our open positions.

Seniority level

Mid-Senior level

Employment type

Full-time

Job function

Business Development, Management, and Consulting

Industries

Medical Practices