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