Sr. Specialist - AAGI A&H Pre-Arrangement & Admission

Job Summary :

Being responsible for Pre-authorization process here are 2 parts which are pre-arrangement part (pre-approve for procedure/surgery) and admission part (initial approval for admission). We service both providers and members each day as shift work from 8 am – 5 pm every day.We pay more attention both medical necessity and cost containment to control the treatment cost in a procedure which the providers have the package price. These process make the customers have a good benefit management under customary price and our business get more cost saving

1). Reviews claim and medical reports (medical indication assessment)  
-  Verify the eligibility of the claim by using and applying the medical knowledge to pre-arrangement cases.
-  In case of medical issues such as medical necessity for the procedures have to consult medical consultant team.
-  Applies all medical necessity guidelines (Thai Medical Practice Guidelines), determine coverage and apply all cost containment measures.
-  Sending the criteria checklist to consultant doctor and benchmark price & LOS comparison.
-  The conclusion and issuing the confirmation letter to the providers within SLA (3 days)
-  Control the cost-effectiveness of medical care and ensure that any new clinical procedures, drugs or technology are appropriate and safe for our customers.
-  Study and understand A&H policy & coverage to apply pre-arrangement and admission part.
-  Coordinate with Internal team such as corporate key account, care coordinator, Medical  team, and External team such as utilization nurses from the hospital.

2). Collaboration process with Health Concierge, Health Solutions & Care Coordination team step as below ;
-  Screening the case which meets the criteria for collaboration project or package.
-  Sending the criteria checklist to consultant doctor.
-  Benchmark price & LOS comparison.
-  Package price checking of each provider.
-  Provider negotiation.

3).Detects suspicious, fraud or abuse claim by providers and refer to Clinical Governance Team. 
4).Process Cooding (ICD codes) based on medical procedures and the claim process

Quaifications :

1. Minimum 3 years in nursing expirience.
2. Nurse in critical units such as ER, ICU, OR will be an advantage.
3. Able to work in commercial environment and fast moving business.
4. Excellent interpersonal and communication skills.

AAGI