Job Summary :

Being responsible for Pre-arrangement part (pre-approve for procedure/surgery) We service both providers and members each day as shift work from 8 am – 5 pm (Mon-Fri). 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

Job Responsibilities :

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.
4).Process Coding (ICD codes) based on medical procedures and the claim process.

Qualifications :

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

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