Case Manager

Job Description

Coordinates with multiple departments, including physicians, nurses, ward managers, the hospital administration team, and the insurance department, to minimize financial risks under the Diagnosis-Related Group (DRG) by providing financial advice and monitoring claims utilization. Enhances clinical documentation and International Classification of Diseases (ICD) coding accuracy through education, collaboration, and adherence to Dubai Health Insurance Corporation (DHIC) guidelines, ensuring support for insurance claims. Acts as a liaison between physicians and the insurance department to address queries raised by payers, facilitate seamless communication, and assist during insurance companies’ front-end audits.

Responsibilities

• Coordinates with various departments, including physicians, nurses, ward managers, the administration team, and the insurance department, to minimize financial risks under the Diagnosis-Related Group (DRG) by providing financial advice; also liaises externally with payers.
•    Monitors claims for utilization under DRG and provides financial advice to the clinical team based on findings.
•    Enhances clinical documentation by educating physicians and nurses as needed to ensure it supports insurance claims and appropriate DRG assignments; queries physicians when required.
•    Improves coding accuracy by collaborating with coders and coordinating with physicians to adhere to proper coding practices and Dubai Health Insurance Corporation (DHIC) guidelines.
•    Supports the insurance department and physicians in responding to queries raised by payers using available documentation.
•    Acts as a link between physicians and the insurance team to ensure smooth communication.
•    Discusses and assists the insurance department during front-end audits conducted by insurance companies.

Qualifications

QUALIFICATIONS & SKILLS:

• Bachelor’s Degree in Medicine/Surgery or Doctor of Medicine
• Certified Coding Specialist (CCS), Certified Coding Associate (CCA), or Certified Procedural Coder (CPC)
• Certified Professional Medical Auditor (CPMA) or Certified Documentation Improvement Practitioner (CDIP) preferred
 

PROFESSIONAL EXPERIENCE:

• Minimum of eight (8) to twelve (12) years of experience in a Revenue Management department.
• Knowledge of DHA Adjudication Guidelines and JCIA Standards.
• Knowledge of Patient Journey, Revenue Cycle, Billing, and Claiming processes.
• Skills in International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) or International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding, Current Procedural Terminology (CPT) coding, and Diagnosis-Related Group (DRG) coding.