Sr. Specialist - AZAY Pre-Arrangement & Admission

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 
-  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 L&H policy & coverage to apply pre-arrangement part.
-  Coordinate with Internal team such as Medical team,Claim team and External team such as utilization nurses from the hospital.
-  Summary monthly report in assigned area.

2). Collaboration process with Provider management team, Health Concierge, Health Solutions step as below ;
-  Screening the case which meets the criteria for collaboration project such as Prefferd hospital, Premium Public hospital or package.
-  Package price checking of each provider.
-  Provider (Hospital) negotiation.

3). Detects suspicious, fraud or abuse claim by providers and refer to Retrospective review and Concurrent review team.
3). Detects suspicious, fraud or abuse claim by providers and refer to Retrospective review and Concurrent review team.

Any AI-future skills e.g., ChatGPT, or CoPilot 365, will be an advantage.

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