Case Management Specialist

Core Responsibilities:- • Coordinate the review of elective surgical requests with designated medical leaders and OR teams to confirm procedure details, clinical feasibility, and documented medical necessity. • Validate procedure codes and case specifications against approved medical coding standards and hospital service definitions. • Work with Accounting/Finance to prepare itemized, accurate pricing offers and identify minimum acceptable prices using approved cost and profitability parameters. • Submit case offers to insurance providers, verify coverage limits and exclusions, and follow up on preauthorizations and pending approvals. • Prepare discount scenarios for eligible case components, including physician fees, accommodation, and service charges, within the approved discount matrix. • Coordinate eligible case transfers across CHG hospitals, including AKH, when clinical capability or capacity is unavailable, in liaison with Admissions and Patient Relations. • Maintain a case tracker and issue daily reports covering quotations, insurer approvals, discounts, case outcomes, transfers, and relevant revenue indicators. • Escalate clinical, capacity, authorization, or pricing exceptions to the Case Manager and designated approving functions for timely resolution. • Work with Patient Relations and Admissions to communicate clear case offers, coverage gaps, expected patient contributions, and approval status. • Ensure procedure coding, medical feasibility, pricing, discounts, and patient transfers follow applicable clinical governance and Group approval procedures. • Maintain complete, confidential, auditable records of clinical validations, pricing calculations, insurance correspondence, approvals, and transfers. • Prepare performance summaries for the Central Pricing Committee covering case conversion, revenue, approved discounts, turnaround time, and patient feedback. Requirements:- • Bachelor's degree in Medicine. • Minimum 5 years of clinical experience, with familiarity with elective surgical procedures. • Knowledge of Surgical pathways, procedure coding, medical necessity, and hospital admission processes • Knowledge of Healthcare case pricing, cost elements, profitability thresholds, and insurance preauthorization • Knowledge of Insurance benefit limits, healthcare confidentiality, and clinical/financial approval workflows • Ability to Validate case information, identify pricing/coverage gaps, and maintain accurate documentation • Ability to Coordinate multiple elective cases and escalate clinical or financial exceptions promptly Show more Show less