Job DescriptionTo resolve internal escalations of non-approved pre-authorization cases on time and restore member confidence through clear communication and coordinated clinical review.
End-to-End Escalation & Recovery Case Management
- * Handle internal escalations of non-approved pre-authorization cases.
- Coordinate clinical review of escalated cases.
- Coordinate with Medical, Operations and Customer Care to resolve cases on time.
- Track open escalations to control the case backlog.
Member Recovery & Service Excellence
- * Conduct recovery reviews for predefined eligible cases.
- Contact members to understand and address their concerns.
- Communicate case outcomes to members clearly.
- Follow up after adverse service experiences to restore member confidence.
Continuous Improvement & Root Cause Analysis
- * Analyse escalations, complaints and rework drivers to identify root causes.
- Identify process gaps and improvement opportunities.
- Recommend corrective and preventive actions for approval.
- Coordinate agreed actions with cross-functional stakeholders.
Skills
- * Healthcare insurance operations and pre-authorization processes
- Medical policy and benefit interpretation
- Case management and service recovery methodologies
- Customer experience and complaint management
- Healthcare analytics and performance reporting
- Quality assurance and root cause analysis
- Process improvement and operational excellence
- Data visualization and dashboard interpretation
- Risk assessment and escalation management
- Communication, stakeholder management and negotiation skills
Education
Medicine and Surgery
