UCR Case Management

Almoosa Specialist Hospital; Eastern Province; On-site; SAR 120,000 - 150,000; Full time

Job summary

A healthcare institution in Saudi Arabia is seeking a qualified professional to join their team. Candidates should possess a Nursing Degree and have a minimum of three years of experience in a hospital environment. The role includes performing reviews of care episodes, collaborating with multidisciplinary teams, and ensuring quality patient care. Expertise in coding methodologies and hospital information systems is essential. The institution values individuals who treat patients with respect and provide quality support to promote recovery.

Qualifications

• Minimum of three years’ experience in a large hospital or health management organization.
• Familiarity with insurance industry standards, especially in a managed care setting.

Responsibilities

• Perform concurrent and retrospective reviews of care episodes.
• Collaborate with the multidisciplinary team on financial issues.
• Provide personalized coordinated care and education to patients.

Skills

Understanding of coding methodologies such as ICD-10 DRG and CPT

Well experienced with hospital information systems

Extensive knowledge of surgical procedures

Fluent in written and spoken English

Education

Nursing Degree or Diploma from a recognized School of Nursing

Job description

Duties and Responsibilities

• Performs perspective review to determine the following;
• If insurance coverage and benefits are verified.
• If managed care program requirements are met.5.1.3Care is rendered at the most appropriate level of care.
• Selection of provider is appropriate and within the preferred network if possible.
• Initial length of stay (LOS) is determined if the patient is inpatient
• Determines if appropriate service codes have been selected
• Determines if all investigations, tests, procedures and visits have been captured during the care episode.
• Assessment needs /discharge planning is initiated.
• Performs concurrent review of care episodes while the patient is in the Health Facility to determine the following:
• Accurate patient information is captured in a timely fashion.
• Care continues to be provided at an appropriate level of care and with the appropriate utilization of resources.
• Care is coordinated
• Insurance coverage benefits still match the patient's requirements.
• Financial criteria of discharge screening are met.
• Performs retrospective review of case files to audit care episodes for claims preparation and/or justification and analysis purposes.
• Attend daily meetings to enhance communication between Multidisciplinary purposes.
• Obtain medical justification reports and other related documents required to enhance the approval process.
• Collaborate with the multidisciplinary team in the identification of financial issues related to the treatment plan and the solving of these issues.
• Responsible for disseminating of any financial data to the multidisciplinary team within the service that they are allocated to.
• Participate in continuous quality improvement through interdisciplinary team measurement, assessment and improvement of patient care delivery processes and services resulting in enhanced quality and appropriate resource management.
• Collaborate with all members of the utilization and Clinical Review Department to enhance all aspects of the resource utilization management program.
• Provide personalized coordinated care, support and treatment for patients and families.
• Treat people with dignity, compassion, and respect.
• Involve patients,familiesand caregivers by providing them with education and resources for offering optimal support to promote recovery.
• Ensures confidentiality of all patient records and derived data.
• Attends mandatory ASH orientation programs and participate in the Departmental orientation and in-service training programs
• Performs any other tasks and duties appropriate to his / her.
• realm of knowledge, skills and experience, as required by the Department Head

Qualifications

Nursing Degree or Diploma from a recognized School of Nursing or College Degree in a related healthcare field

Professional Experience

• Minimum of Three (3) years’ experience in a large hospital or health management organization (HMO) with demonstrated clinical and administrative skills.
• Familiarity with application of insurance industry standards, preferably in a managed care setting. Minimum of 2 years practical experience in Direct care service.

Specialized Skills

• Understanding of coding mythologies such as ICD-10 DRG and CPT.
• Well experienced with hospital information systems and personal computer software programs.
• Extensive knowledge of surgical procedures.
• Fluent in written and spoken English