Case Management Specialist

Allianz; Pennsylvania; On-site; USD 90,000 - 120,000; Full time

Job summary

Allianz Partners is seeking a Case Management Utilization Review Specialist to drive cost-effective case handling and ensure compliance in a fast-paced environment. The role requires MBBS and at least five years of medical experience, preferably within an insurance context, with legal work authorization in the United States.

You will train the team, manage high-risk cases, and coordinate with providers and payers.

Qualifications

• Bachelor’s of Medicine (MBBS) required and licensed.
• Minimum 5 years medical experience with insurance context preferred.
• Legal work authorization to operate in the United States.

Responsibilities

• Liaise with Case Management to develop and implement protocols and train the team.
• Identify and report clinical cost drivers to plan Field Control Officers or File Reviews.
• Manage high-risk and long-stay cases.
• Evaluate Provider & Clinician Abuse to flag cost issues and create a cost-control framework.
• Coordinate with BD Team & Payers to align expectations from Case Management perspective.
• Audit and sign off monthly Case Management Savings reports and share with Assistant Manager.
• Coordinate with Providers & Vendors for cost-effective outcomes on elective cases.
• Ensure timely closure of disputed cases with insurance Payers.
• Work with Audit and Fraud Waste teams to flag misrepresentation or malpractice.
• Support AI-readiness initiatives and data-driven decision making.

Skills

5+ years medical practical experience

Internet research

Analytical thinking

Education

Bachelor of Medicine (MBBS)

Tools

MS Excel

MS Word

MS Outlook

MS PowerPoint

Job description

Case Management Utilization Review Specialist manages high-cost cases ensuring departmental goals are met, timelines are adhered to, and all compliance measures are taken care of. This report directly reports to Assistant Manager – Case Managent Utilisation Review.

What you do

• Liaise with the Case Management team to develop and implement case management protocols, as well as provide training for the team.
• Identifying and reporting clinical cost drivers to plan Field Control Officers or File Reviews.
• Managing high risk and long stay cases.
• Evaluating Provider & Clinician Abuse to red flag the team . Create a framework for cost controls.
• Coordinating with BD Team & Payers to manage the expectations from Case Management perspective
• Auditing & Signing off the monthly case Management Savings report & sharing with the Assistant Manger.
• Manage Jumbo discounts above 250k AED claim value
• Coordinate with Providers & vendors to get the best cost effective outcome for elective cases
• Ensuring timely closure of disputed cases & cases pending with insurance Payers.
• Achieve a monthly savings target of AED 1M in line with the criteria or methodology defined by the Line Manager and Head of Department.
• Work closely with the Audit and Fraud Waste team to flag providers and clinicians with activities of misrepresentation or malpractice.
• Ensure timely reviews & deicision making of High costs cases above AED 75,000.
• Assessing cases with multiple admissions and readmission to gauge the provider practice as well as investigate the medical negligence if any.

• AI READINESS Work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics and cloud-based tools, using insights responsibly with our standards of data governance, security and ethical use.

What you bring

• Bachelor’s of Medicine (MBBS);
• 5+ years medical practical experience (reputable insurance provider, broker or a TPA experience a plus).
• Knowledge of overall insurance industry practices is a plus.
• Legally permitted to work in the country of operations.
• Physically fit to carry out duties.
• Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.

What we offer

Allianz Partners is a world leader in B2B2C insurance and assistance, offering global solutions that span international health and life, travel insurance, automotive and assistance. Customer driven, our innovative experts are redefining insurance services by delivering future-ready, high-tech high-touch products and solutions that go beyond traditional insurance. Our products are embedded seamlessly into our partners’ businesses or sold directly to customers, and are available through four commercial brands: Allianz Assistance, Allianz Automotive, Allianz Travel and Allianz Care.

At Allianz Partners, Artificial Intelligence (AI) is transforming service delivery and innovation. By leveraging Business Intelligence and Data Analytics, we enhance strategic decision-making and customer experiences. Our commitment to Ethical AI ensures responsible deployment, maintaining data integrity and trust. Conversational AI improves communication, while Emerging Technologies and Generative AI drive industry leadership and new opportunities. With robust Information Security Management, we protect sensitive information, ensuring compliance and security. Embrace the future of AI with Allianz Partners, where possibilities become realities.