Qualifications, Experience and Skills required:

• Diploma/bachelor’s degree in nursing
  
• Minimum 3 years nursing experience, both in acute / or critical care settings
  
• Minimum 2 years Care Management within insurance or corporate healthcare
  

Technical & professional competencies

• Hospital care coordination and utilization management
  
• Knowledge of clinical pathways and insurance benefit structures
  
• Understanding case-based costing added advantage
  
• Proficiency in hospital EHR and digital health systems
  

Personal characteristics & behaviors

• Strong communication skills & interpersonal skills
  
• Analytical and problem-solving ability
  
• Team player with resilience and patience
  
• Ethical decision making with high integrity
  

Corporate Relationship and Business Support

• Maintain strong relationships with Corporate Care Managers & TPA’s.
  
• Conduct one-to-one engagement with the care managers.
  
• Identify gaps in service delivery and give feedback to management.
  
• Explore business development opportunities which the hospital can take advantage of.
  
• Monitor & evaluate referrals from these corporate.
  

Corporate Operational Guidelines

• Coordinate smooth execution of corporate operational guidelines.
  
• Clinical Care, Coordination and Facilitation
  
• Coordinate care for scheme beneficiaries across inpatient, outpatient and diagnostic s
  
• Identifying high-risk patients (high cost, prolonged length of stay and re-admissions)
  
• Liase with clinicians to ensure timely service delivery aligned to patient needs and cover limits.
  
• Monitor the inpatient progress in the hospital.
  

Utilization/Financial management.

• Conduct utilization review for high cost and prolonged admissions
  
• Verifying itemized bills on daily basis and coordinating the same with the corporate care managers.
  
• Confirm benefits, limits and authorization to ensure appropriately and verify coverage and benefit with health insurer to ensure that the patient is appropriately billed.
  
• Coordinating availability of required services.
  

Advocacy Education Communication

• Advocates for the patients under specific schemes for needed services and educate accordingly, based on their limited cover.
  
• Coordinate communication between patients, clinicians, insurers and corporate partners.
  
• Resolve issues arising from patients, families, clinicians and payers.
  

Digital Health, Data & Reporting

• Utilize hospital information systems to track admissions, LOS, Utilization and discharges.
  
• Prepare periodic care management and utilization reports for management
  
• Support data- driven decision making for service improvement