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 Management Utilization Review.

Responsibilities

• 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 and 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 and sharing with the Assistant Manager.
• Manage jumbo discounts above 250k AED claim value.