Manager - Healthcare Services
Role Overview
Resolve internal escalations of non-approved pre-authorization cases on time and restore member confidence through clear communication and coordinated clinical review.
Key Skills for This Role
Full Job Posting
Role purpose
Resolve internal escalations of non-approved pre-authorization cases on time and restore member confidence through clear communication and coordinated clinical review.
Escalation and recovery case management
- Handle internal escalations of non-approved pre-authorization cases and coordinate clinical review.
- Work with Medical, Operations, and Customer Care to resolve cases on time and track open escalations to control backlog.
- Conduct recovery reviews for predefined eligible cases; contact members to understand and address concerns.
- Communicate case outcomes clearly and follow up after adverse service experiences to restore member confidence.
Continuous improvement
- Analyze escalations, complaints, and rework drivers to identify root causes.
- Identify process gaps and improvement opportunities and 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, service recovery, customer experience, and complaint management.
- Healthcare analytics, performance reporting, quality assurance, and root cause analysis.
- Process improvement, operational excellence, data visualization, and dashboard interpretation.
- Risk assessment, escalation management, communication, stakeholder management, and negotiation.
Education
- Medicine and Surgery.
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