مدير - خدمات الرعاية الصحية

Job Description

To resolve internal escalations of non-approved pre-authorization cases on time and restore member confidence through clear communication and coordinated clinical review.

End-to-End Escalation & Recovery Case Management

• Handle internal escalations of non-approved pre-authorization cases.
• Coordinate clinical review of escalated cases.
• Coordinate with Medical, Operations and Customer Care to resolve cases on time.
• Track open escalations to control the case backlog.
  
  

Member Recovery & Service Excellence

• Conduct recovery reviews for predefined eligible cases.
• Contact members to understand and address their concerns.
• Communicate case outcomes to members clearly.
• Follow up after adverse service experiences to restore member confidence.
  
  

Continuous Improvement & Root Cause Analysis

• Analyse escalations, complaints and rework drivers to identify root causes.
• Identify process gaps and improvement opportunities.
• Recommend corrective and preventive actions for approval.
• Coordinate agreed actions with cross-functional stakeholders.
  
  

Skills

• Healthcare insurance operations and pre-authorization processes
• Medical policy and benefit interpretation
• Case management and service recovery methodologies
• Customer experience and complaint management
• Healthcare analytics and performance reporting
• Quality assurance and root cause analysis
• Process improvement and operational excellence
• Data visualization and dashboard interpretation
• Risk assessment and escalation management
• Communication, stakeholder management and negotiation skills
  
  

Education

Medicine and Surgery