Quality Assurance and Case Manager at Reliance HMO

The Position

• The ideal candidate will work with our Provider Relations, Customer Success, Claims and Underwriting teams and make sure that excellent and high quality service is provided to our clients across all provider networks while ensuring resolution of complicated claims and limiting fraud
• You will have major responsibility for managing the relationship between the company, our providers, and our enrollees. You will facilitate the delivery of prompt services for clients as required on a case by case basis and maintain a healthy cost-quality balance as far as patient care is concerned
• You will track waste, fraud, and/or error from initial point of access to care by enrollees to final claims filing by the Provider

You’ll love this opportunity because…

• ...you'll have a clear career path
• ...you'll have a lot of independence in managing projects
• …we have a vibrant and active culture
• …co-workers are a close-knit, intelligent, and motivated team

Key Responsibilities

• Work with the Provider Team to ensure the minimum standards for quality are met before sign up.
• Inspect and evaluate hospitals to ensure compliance with basic standards.
• Carry out physical inspection at the assigned provider’s office using the checklist.
• Investigate complicated claims by checking the case folder and speaking to the Enrollee and the doctor.
• Escalate fraudulent cases to the Committee of Doctors.
• Update Providers’ dashboard, and implement resolutions.
• Recommend changes to improve the efficiencies in the systems and process of the Provider Relations as well as the Claims team.
• Recognize and fix areas of weakness in the system to limit potential for fraud
• Carry out regular hospital quality checks.
• Develop and implement survey tools for patient feedback and communicating data results to Providers to ensure continuous improvement.
• Visit patients in the hospital to ensure they are getting medically necessary care, quality care and that the care is being delivered as efficiently and economically as possible.
• Anticipates the patient’s future health care needs and tries to put in place mechanisms to meet those needs as efficiently as possible
• Ensure efficiency and cost effectiveness of medical services provided to clients
• Takes initiative to present ideas and suggestions to leadership
• Maintains knowledge and proficiency in medical practices through continuing education, staff meetings, and workshops.
• Perform all other duties as assigned.

Requirements
Must Haves:

• Must be a Medical Doctor with at least 2 years of experience in similar role.
• Strong ability to make judgment on medical / surgical cases in relation to benefits listed on enrollee’s plan.
• Ability to make professional judgment on coverage and non-coverage of care requests per time, based on the enrollee’s benefits table.
• Exceptional problem solving and analytical skills
• Excellent communication and presentation skills
• knowledge of, and sensitivity to, cultural and language differences.
• Must be able to work as a team member and develop productive and cooperative working relationships with all members of the RHMO team
• A demonstration of curiosity, love for learning, execution and speed.

Some Perks and Benefits

• Daily meals
• Employee-friendly working conditions
• Generous health insurance package; including gym passes
• Modern, cosy and collaborative workspace.