Case Management Lead

We are seeking a dedicated and dynamic Case Manager to join our Allianz Partners NEXtCARE - Third-Party Administrator (TPA) team. The Case Manager will be responsible for managing the end-to-end process of claims, ensuring timely resolution and providing exceptional service to our clients and policyholders. This position requires a keen eye for detail, strong communication skills, and the ability to manage complex cases effectively within a fast-paced environment.

Key Responsibilities:

1. Case Management:

•Manage and oversee the entire claims process for assigned cases, ensuring all necessary actions are taken from initial claim intake to resolution.

•Serve as the primary point of contact for both internal and external stakeholders (clients, policyholders, healthcare providers, and insurers) throughout the claims process.

•Evaluate claims for eligibility, benefits, and coverage, ensuring that all claims are processed efficiently and according to company policies and procedures.

•Active case management for high-cost elective cases for home country, SMO and long-term care routing.

•Physical regular file audits in the facilities for effective evaluate and manage over utilization, malpractice, iatrogenic injuries, mismanagement, mis presentation, retrospective audits, up-coding of DRGs, cost containment, also to control average claim cost and average length of stay.

2. Claims Coordination:

•Coordinate and communicate with healthcare providers, hospitals, and other service providers to gather information, ensure proper documentation, and facilitate the claims process.

•Excellent Negotiations skills to bring the claim cost down.

•Review medical records, treatment plans, and other documentation to determine the appropriate action and ensure that claims are paid correctly.

3. Customer Service & Support:

•Provide proactive support to clients and policyholders by answering queries, providing updates, and offering solutions to resolve any issues.

•Ensure a high level of customer satisfaction (Payers and Providers) by addressing concerns and complaints promptly and professionally.

4. Claims Assessment:

•Analyze claims to assess the appropriateness of services and ensure that all claims are in line with NEXtCARE policies, guidelines, and legal requirements.

•Review medical treatments and services to identify any discrepancies or areas requiring further investigation or clarification.

5. Documentation & Reporting:

•Maintain accurate and up-to-date records of all claims, communications, and actions taken for internal and external audits including the savings done.

•Prepare reports on case status, claims trends, and areas for improvement, as required by management.

6. Compliance & Quality Assurance:

•Ensure compliance with all relevant regulations, including health insurance laws, privacy regulations (such as HIPAA), and company policies.

•Participate in internal quality assurance processes, providing feedback to improve claims management and operational efficiency.

7. Collaboration:

•Work closely with cross-functional teams (claims adjusters, medical case managers, legal, underwriting, call center, BDU, account managers and finance) to ensure effective case resolution and timely decision-making.

Requirements:

•Minimum of 2-3 years of experience in case management, claims management, or a related role within a TPA or insurance environment.

•Experience in health insurance or medical claims management is highly preferred.

•Strong understanding of claims processes, insurance policies, and healthcare industry regulations.

•Excellent communication skills, both written and verbal, with the ability to interact with a variety of stakeholders.

•Excellent negotiations skills.

•Strong analytical and problem-solving abilities.

•Ability to manage multiple cases efficiently while ensuring accuracy and compliance with regulations.

•Attention to detail and strong organizational skills.

•Proficiency with claims management software and Microsoft Office Suite.

•Bilingual (English/Arabic) is a plus, depending on location.

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.

Allianz Partners is a global leader in providing innovative Einsurance and assistance services across the globe. As part of Allianz Group, we focus on delivering exceptional customer experiences, offering a broad range of tailored services that meet the evolving needs of individuals and businesses worldwide.