Manager, Clinical Excellence

Job Description

To manage inpatient cases onsite and across the care journey, ensuring care is clinically appropriate, of high quality, patient-centered and cost-efficient.

Medical Outcomes Management and Monitoring

· Apply evidence-based clinical guidelines and protocols to inpatient cases.

· Conduct clinical case reviews for medical necessity and appropriateness.

· Manage complex and high-risk cases, escalating where required.

· Assess care pathways, quality of care and outcomes across internal and external care channels.

Conduct medical FIs and hospital profiling.

Patient-Centric Service

· Apply patient- and member-centric principles in clinical care management processes.

· Balance clinical appropriateness, cost efficiency and customer experience in care decisions.

· Conduct proactive engagement with high-risk and chronic patients to improve experience and outcomes.

· Coordinate with onsite and third-party providers on quality checks and documentation, and address failures promptly.

Support third-party customer relationship management programmes.

Utilization & Cost Management

· Review admission appropriateness and level of care.

· Review inpatient utilisation promptly, within the agreed standards of the inpatient end-to-end management programme.

· Monitor length of stay and support discharge planning.

· Identify high-cost cases and recommend interventions and cost-containment initiatives.

· Audit and report fraud, coding abuse and non-compliance with coding standards.

Onsite Adjudication

· Verify, audit and report all inpatient services incurred.

· Review and process inpatient claims onsite against medical policy, line items, invoices and adjudication guidelines, cross-checking physical and electronic claims data.

· Apply medical judgement and agreement terms and conditions to prevent abuse, fraud and overtreatment.

· Escalate high-profile and high-value claims for decision.

· Coordinate with hospitals to resolve inpatient claim issues.

Quality Management

· Apply quality standards across clinical care management.

· Conduct clinical quality assurance and quality control checks.

· Monitor adherence to clinical guidelines, protocols and regulatory requirements.

· Track quality indicators in daily operations and recommend improvements that standardise clinical practice.

· Document clinical decisions to support audit and compliance.

Skills

· Bachelor’s degree in medicine and surgery or equivalent

· Master’s degree preferred

· Excellent interpersonal and communication skills

· Ability to explain complex medical information to patients and their families

· Problem-Solving

· Patient-Centred Care

· Decision-Making

· Knowledge of healthcare regulations and compliance

· Healthcare and customer relationship experience

· Hospital management experience is preferred