Casemix Manager

Siloam Hospitals Group; Tangerang; Hybrid; IDR 240,000,000 - 480,000,000; Full time

Job summary

Siloam Hospitals Group in Indonesia seeks a BPJS Quality & Financial Analyst to manage BPJS services, ensuring quality and cost efficiency across units. You will collaborate from strategic planning to operational development with hospital leaders and AMA.

Responsibilities include analyzing BPJS patients by service, monitoring billing vs reimbursement, and maintaining data accuracy while expanding the BPJS network and ensuring regulatory compliance.

Qualifications

• Bachelor Degree from any related major (preferably in Medical Department).
• Minimum 2 years work experience in health or quality management; quality projects or internal audit is a plus.
• High attention to detail to ensure accuracy in coding and data reporting.
• Strong problem-solving to address and resolve issues related to case mix data and coding practices.
• Proficiency with coding systems such as ICD, DRG, and other classification systems used in healthcare.

Responsibilities

• Manage BPJS service quality and costs across units and analyze BPJS patients by service.
• Collaborate with hospital leaders (CEO, Hospital Director, AMA) from strategic planning to operational development.
• Analyze gross margins for BPJS patients by service type and treatment.
• Monitor the difference between hospital billing rates and BPJS reimbursement amounts to identify more profitable BPJS cases.
• Collaborate with AMA, Finance, Marketing, and clinics to improve referrals.
• Hold regular meetings with Siloam clinics, non-Siloam clinics and other related hospitals for priority referrals.
• Collaborate with AMA and Hospital Director to improve performance of low utilization equipment.
• Build and expand Siloam's network in the health industry.

Skills

Quality management

Attention to detail

Problem solving

ICD/DRG coding

Education

Bachelor degree in medical/related

Job description

• Manage the quality and costs of services/care provided to BPJS patients and be responsible for carrying out various initiatives, both strategic and operational, including analyzing BPJS patients by each service unit, ensuring positive internal referrals, and building good relationships between units and related external parties.


• Collaborate with hospital leaders (CEO, Hospital Director, AMA) related to BPJS, starting from strategic planning to operational development.


• Collaborating with Finance to conduct an analysis of gross margins for BPJS patients based on type of service (craft groups) and treatment.


• Monitor the difference between hospital billing rates and BPJS reimbursement amounts to identify more profitable BPJS cases.


• Collaborating with the Siloam marketing and clinic team.


• Hold regular meetings with Siloam clinics, non-Siloam clinics and other related hospitals to get priority referrals.


• Collaborate with AMA to improve performance of low utilization equipment.


• Building and expanding Siloam's network in the health industry.


• Collaborate with the medical team to manage the average length of stay (“ALOS”) for BPJS patients.


• Review and carry out daily supervision for BPJS patients based on daily reports from RMO for IPD cases.


• Maintaining the estimated number of claims in the web application and communicating it with specialist doctors.


• Conduct discussions with AMA and/or Hospital Director regarding difficult or special cases.


• Collaborate with the hospital director to build good relations with the relevant BPJS.


• Provide the latest information to the BPJS team (both clinical and administrative staff) regarding developments or updates in BPJS regulations.


• Communicate with the medical team (specialists and RMO) and pharmacy to review the services/procedures/examinations provided to BPJS patients, starting from the reception of IPD patients and/or based on daily reports until the patient is discharged (including if there are follow-up examinations).


• Provide advice to the medical team about cases that will be referred back to the clinic/Puskesmas or to refer to another hospital according to the patient's needs and condition.


• Ensure that the rooms provided are in accordance with the specified patient class and/or patient top-up standards (if any).


• Supervise the use of prescription drugs and consumption of consummable goods for BPJS patients.


• Review the status of case claims recorded by the Internal Verificator in the application.


• Collaborate with Internal Verifiers and specialists to resolve problems related to claims rejected by BPJS.


• Ensure compliance with BPJS regulations and prevent cases of fraud.


• Bachelor Degree from any related major (preferably in Medical Department)


• any related major (preferably in Medical Department)


• Have minimum 2 years work experience in the field of health or quality management, having experience in quality projects or internal audit will be plus


• High attention to detail to ensure accuracy in coding and data reporting.


• Strong problem-solving skills to address and resolve issues related to case mix data and coding practices.


• roficiency with coding systems such as ICD, DRG, and other classification systems used in healthcare.

Qualifications

• Bachelor Degree from any related major (preferably in Medical Department)


• Have minimum 2 years work experience in the field of health or quality management, having experience in quality projects or internal audit will be plus


• High attention to detail to ensure accuracy in coding and data reporting.


• Strong problem-solving skills to address and resolve issues related to case mix data and coding practices.


• roficiency with coding systems such as ICD, DRG, and other classification systems used in healthcare.