Case Management Reviewer

MedNet Egypt is one of the leading managed care service organizations serving healthcare needs. We are looking for a skilled Case Management Reviewer to provide services related to medical evaluation, authorization, and case management for inpatient and outpatient insured members/providers. Manages sensitive, high-cost, and complex cases, ensures timely and clinically appropriate decision-making, supports cost containment and care management, handles calls and communications relating to medical cases, and coordinates with payers, providers, internal teams, and insured members in line with applicable policies, medical billing and coding standards, and compliance requirements Your Job: Evaluate cases according to case management triggers and protocols, provide authorizations for insured members, and efficiently manage related calls and communications. Coordinate care between members and providers for sensitive, high-risk, long-stay, high-cost, multiple-admission/readmission, and high-cost medication cases. Ensure timely review and decision-making for high-cost cases based on assigned thresholds. Assess provider practices, medical necessity, and potential medical negligence indicators where identified. Evaluate cases against international medical standards, regulatory requirements, insurance policies, and ICD/CPT coding and billing guidelines. Compile data and prepare monthly statistical reports on case management activities and outcomes. Ensure appropriate medical treatment and cost control through case management interventions and assigned financial targets. Identify and report clinical cost drivers to relevant field control and file review stakeholders. Contribute to the development and implementation of case management triggers and protocols. Audit, validate, and sign off on monthly case management savings reports and share them with the Assistant Manager/Line Manager. Collaborate with Fraud, Waste and Abuse, Provider Management, and Utilization Management teams to identify concerns, flag potential misrepresentation, abusive practices, or malpractice, and provide supporting documentation for corrective actions. Manage medical evaluation and authorization queries from providers, insurance companies, and insured members, while coordinating with Business Development teams and payers to manage expectations. Build positive relationships with clients, healthcare providers, and internal stakeholders, work collaboratively toward strategic targets, and deliver excellent customer service while ensuring appropriate care and maximum client satisfaction. Your Profile MBBS / Bachelor of Medicine and Bachelor of Surgery International coding certification (AHMIA, CPC, CPMA ) will be an advantage. Minimum Experience: 5+ years’ experience, preferably with a reputable insurance provider, broker or TPA; experience in medical claims evaluation utilization review, case management. Knowledge of the UAE local healthcare services system and overall insurance industry practices. Knowledge of ICD and CPT coding guidelines, preferably with certification. Computer literacy and fluency in MS Office (Excel, Word, Outlook, and PowerPoint), general internet navigation, and research Show more