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Clinical Case Manager

by Tiana Liu in Healthcare    19th Apr, 2021    Negotiable

The Clinical Case Manager has the primary goal of individual case management of medical cases as specified by the business to ensure quality care with special focus on balancing financial savings. This role ensures that all parties (broker, company, provider, service partner, colleagues) involved are kept up to date on the progress of authorisation and case details. The Clinical Case Manager will have an integral role in the current case management process, as well as the claims audit and on-site case review.

  • Investigate, and respond to enquiries for complex medical authorisations and high value within certain threshold and criteria claims from members, providers, group secretaries, service partners and intermediaries in the appropriate method, in line with our policy and management style.
  • Pro-actively contact members, providers, service partners and intermediaries via telephone, email, fax and letter to advise on decision of request and fully explain benefit entitlement to all parties.
  • Ensure the correct interpretation of our policy and rules, using the correct compatible combinations of codes for accurate processing of data, in accordance with our service standards and customer expectations
  • Liaise with Global clinical staff to interpret condition and treatment to the rules and regulations of us
  • Liaise with all areas of the business to assist with resolving enquiries, such as claims eligibility, coverage and alternative treatments.
  • Works with audit and pre-authorization teams to identify and investigate any fraud or abuse.
  • Preparing case reports for each investigation performed; keeping record of daily activity for monthly reporting.
  • Identify opportunities to reduce future claim expense for us and to pro-actively provide relevant information to Risk management department
  • Proactively negotiate medical costs and/or medical treatment to achieve either reduced cost to the business or most appropriate treatment for member.
  • Develop and maintain an up to date and accurate knowledge of appropriate our products, policies and initiatives in order to ensure that all queries are answered accurately.
  • Support our BGAIM medical teams to provide provider/specialist recommendation, estimate medical costs helping make appointment, support case management, etc. Achieve departmental and individual KPIs
  • Take responsibility for the logging of written queries and complaints on the customer database, ensuring it is up to date and as accurate as possible.
  • To comply with and take into account any requirements from the local regulators and/or any applicable local regulatory requirements
  • Handling complaints and investigating the root cause to provide clear goal-oriented solutions

Quality Specialist-Medical Devices

by Joey Chen in Healthcare    8th Mar, 2021    Negotiable

Our client is looking for a Quality Specialist for Medical Devices in Guangzhou

  • Set up supplier and product qualification standards and supplier management programs on HSS(Hygiene Safety and Sanitation) category.
  • Deploy the standards and quality management programs to HSS suppliers.
  • Responsible for HSS supplier qualifications (including plant audits/visits), product functional evaluation and qualification on quality and follow up with suppliers on improvements where necessary and provide qualification reports to market applicator.
  • Responsible for HSS supplier quality management and lead on improvement initiatives, manage supplier changes and assure suppliers deliver consistent quality of HSS products to the market.
  • Quality & compliance data collection (e.g. 3rd party audit reports, test reports, certificates, etc.) and keep them update to date.
  • Complaint management including data management; complaint sample validation, root causes analysis with suppliers and monitor the progress; follow-up with suppliers on corrective actions, and report to the market. 
  • Set up and optimize the HSS technical specifications and data sheets with the markets as required. Integrate “voice of customer” and market regulatory requirements into the HSS specifications with the support from compliance team.
  • Work closely with suppliers and the company Compliance and Safety team to monitor and manage supplier quality & compliance performance and drive continuous improvement. Provide supplier quality performance data to Sourcing to understand supplier’s capabilities.

晶雅人事

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