Field Doctor Lead Role

Job description / Role Job Type Full Time Job Location Manama, Bahrain Nationality Any Nationality Salary Not Specified Gender Not Specified Arabic Fluency Not Specified Job Function Healthcare Company Industry Insurance The case management utilization review lead responsibilities The case management utilization review lead is responsible for managing the high-cost cases while ensuring that departmental goals, timeline of activities, and compliance measures are met. What you do Perform complete file review of high-cost claims with regards to the multidisciplinary notes, TPR charts, physician order notes, lab reports, radiology reports, drug chart sheets, consultation notes, nursing notes, progress notes, etc. Field hospital deployment or file audit to be performed when required (non-physical or physical [provider visit]) to capture hospital-acquired infections, mismanagement, iatrogenic injuries, etc. Request any medical documentation or find any missing document which is essential in decision making. Perform review of DRG severity of illness (SOI) in line with revision of CPT codes / ICD codes, which are being up-coded by the provider - if required, discuss with the treating doctor and the medical coders. Perform utilization review for DRG cases and FFS cases with regards to, and not limited to, final bill review, consumables mark ups, non-covered items/services, and overutilization of services. Perform review of claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA, DOH/HAAD, MOH). Pre-authorization and maintaining required output of high-cost claims with detailed insight of claim on day-to-day basis. Adhere to the case management and cost containment protocols for elective high-cost cases and medical management cases. Refer cases for second opinion when deemed necessary to confirm the best mode of management - also for cost containment to lesser negotiating factor (NF) facilities within the member's network or option for home country treatment. Adjudicate high-cost claims at submission level for settlement between the insurer and health care provider as per policy terms and conditions. Adjudicate high-cost claims at precertification level, authorize decision on the claim within policy terms and conditions. Continuously work to identify possible procedure inconsistencies; develop, recommend and implement improvements. Provide support to medical claims officers to close all escalated claims queries within the agreed turn-around time. Achieve a monthly savings target of AED 800,000 in line with the criteria or methodology defined by the line manager and head of department. AI readiness: Work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics and cloud-based tools, using insights responsibly with our standards of data governance, security and ethical use. What you bring Bachelor's of Medicine (MBBS). 3+ years medical practical experience (reputable insurance provider