Nurse Case Manager

Job content

The Global Case Manager joins our newly formed Brighton healthcare hub specialist qualified Nurses who support individual case management of medical cases to ensure quality care for our customers.

This role ensures that all parties involved in the care of the policy holders are kept up to date on the progress of authorisation and case details. The Global Case Management Consultant will also have an integral role in the current case management process, as well as the claims audit and on-site case review.

The team operates core hours between 07:00 - 19:00 including weekends (on a rota based and weekends will be home based), 35 hours a week. Due to the nature of the role you may be asked to work outside those hours to support our global operation.

Responsibilities

• Investigate, and respond to enquiries for complex medical pre-authorization and high value claims from different internal and external shake holders including but not limited to members, providers, service providers and intermediaries in the appropriate method, in line with Bupa Global policy and management style
• Pro-actively contact members, providers, service partners and intermediaries via telephone, email, fax and letter to advise on the decision of requests and fully explain benefit entitlement to all parties.
• Ensure the correct interpretation of Bupa Global’s 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 Bupa Global
• 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-authorisation teams to identify and investigate any fraud or abuse.
• Prepare case reports for each investigation performed. Keeps records of daily activity for monthly reporting.
• Identify opportunities to reduce future claim expense for Bupa Global and to pro-actively provide relevant information to Healthcare Management Team.
• Proactively negotiate medical costs and/or medical treatment to achieve both reduced cost to the business and most appropriate treatment for the member where appropriate.
• Develop and maintain an up to date and accurate knowledge of appropriate Bupa products, policies and initiatives in order to ensure that all queries are answered accurately.
• Supports Bupa’s global medical teams to provide provider/specialist recommendations, estimation of medical costs, appointment booking, support case management, etc.
• Achieve departmental and individual KPIs and keep individual CPD up to date
• Takes responsibility for the logging of all communications whether written or verbal as well as 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
• Handles complaints and undertakes root cause analysis to enable goal orientated future solutions
• Triage of cases to define whether onward referral to one of our specialist partners is appropriate

The ideal candidate:

• Bachelor Degree or above in healthcare or related discipline
• Doctor or RN experience with speciality (local or overseas) is preferred OR excellent medical background with practical medical experience.
• Superior customer service and negotiation skills.
• Solid experience in utilisation review or case management in IPMI environment.
• Knowledge of medical coding systems
• Excellent knowledge of Microsoft Word® and Microsoft Excel® is a must
• Excellent interpersonal skills and ability to work with a team is a must
• Excellent analytical and critical thinking skills
• Respects diversity and embraces cultural difference
• Highly customer focussed and able to place the customer’s at the heart of all their decision making.
• Prepared to visit patients at healthcare providers premises in various locations
• Understand the business commitment to meet deadline and turn-around times.
• Excellent record keeping and reporting skills, with the ability to deliver reporting requirements on time.
• Good judgement and ability to prioritise workflow according to business needs
• Proficient communication skills in English

About the Company

We are a health insurer and provider. With no shareholders, our customers are our focus. We reinvest profits into providing more and better healthcare for the benefit of current and future customers.

Bupa’s purpose is longer, healthier, happier lives and making a better world.

Here you’ll be welcomed. We champion diversity and we understand the importance of our people representing the communities and customers we serve. You’ll find an inclusive environment where you can be yourself and where everyone is driven by the same purpose – helping people live longer, healthier, happier lives and making a better world.

Bupa Global

Bupa Global is the international health insurance division of Bupa. We provide customers who want premium international coverage with products and services to access the healthcare they need anytime, anywhere in the world, whether at home or when studying, living, travelling or working abroad.

Bupa Global has offices around the world including London and Brighton (UK), Miami (USA), Copenhagen (Denmark), Dubai (UAE, in partnership with OIC), and Hong Kong (China) as well as regional offices in mainland China, Singapore, Egypt, Mexico, the Dominican Republic, Bolivia, Brazil, Panama, Guatemala and Ecuador.