Case Manager NMC healthcare LLC

The Case Manager is responsible for coordinating patient care, managing insurance approvals, monitoring resource utilization, and ensuring efficient discharge planning while supporting the Revenue Cycle Department. The role focuses on optimizing insurance approvals, reducing claim denials, ensuring medical necessity documentation, and improving hospital revenue through effective case and utilization management in compliance with UAE healthcare regulations.

Responsibilities

1. Case Management & Care Coordination

• Assess patient medical and clinical needs 

• Coordinate with physicians and nursing teams for treatment planning 

• Monitor patient progress and length of stay 

• Identify high-risk and long-stay patients 

• Facilitate patient transfers in collaboration with clinical teams, ensuring medical records, treatment plans, and discharge documentation are complete.

  
  

2. Insurance & Revenue Cycle Coordination

• Coordinate with insurance companies and TPAs for approvals through the RCM Approval unit

• Ensure timely pre-authorizations and concurrent approvals 

• Monitor insurance coverage and eligibility 

• Support denial prevention and claim accuracy 

• Work closely with billing and coding teams 

• Ensure proper clinical documentation for claims submission 

• Facilitate insurance company and TPA visits for medical file reviews and case audits.

• Monitor and ensure timely bill updates by coordinating with clinical, coding, and billing teams to avoid claim delays and ensure accurate revenue capture.

  
  

3. Real-Time Visibility & Escalation of Inpatient Pending Approvals

• Maintaining real time tracking of all Inpatient pending approvals and escalate cases exceeding defined turnaround times to relevant stakeholders (Clinical team, RCM insurance).

4. Utilization Management

• Monitor Average Length of Stay (ALOS) 

• Ensure efficient use of hospital resources 

• Conduct concurrent and retrospective case reviews 

• Support cost-effective treatment planning 

• Ensure compliance with payer guidelines 

5. Discharge Planning

• Coordinate safe and timely discharge 

• Ensure discharge documentation is complete 

• Coordinate follow-up care and insurance approvals 

6. Documentation & Compliance

• Coordinate with the clinical team to ensure proper and complete medical documentation to support insurance approvals, coding, and billing requirements.

• Maintain accurate case management records 

• Ensure compliance with health regulations, Insurance policies, and hospital revenue cycle policies 

• Support Insurance audits 

• Prepare utilization and case management reports 

7. Revenue & Quality Support

• Reduce insurance rejection rate 

• Improve approval turnaround time 

• Support revenue optimization 

• Monitor case management KPIs 

  • Insurance Inpatient approval turnaround time 

    • Reduce Rejection Rate 

    • Average Length of Stay (ALOS) 

    • Claim documentation accuracy 

    • Discharge efficiency 

    • Revenue cycle support performance 

    • Utilization review compliance 

    • Patient throughput

• Participate in revenue cycle and clinical meetings