About This Role
This nursing role focuses on ensuring optimal patient journeys and cost-effective care by acting as a clinical liaison with partner hospitals. The Utilization Case Manager coordinates with hospitals, guides treatment pathways, and enforces insurer protocols to align clinical and financial outcomes with quality and efficiency standards. This position is ideal for a clinical professional who excels in communication, patient advocacy, and data-driven care coordination.
Responsibilities
- Validate and provide real-time recommendations on the appropriateness of hospital admissions for simple disease and day surgery eligible procedures to capture efficiency savings
- Validate the appropriateness of length of stay daily for eligible simple disease and other upcoming conditions in scope, according to AIA’s LOS benchmark
- Discuss member benefits with the admitting doctor and nurse to optimize the treatment plan based on the member’s benefit scope
- Facilitate AIA-related requests raised from the hospital to improve overall insurer/provider/member experience (e.g., coordinating pre-authorization and concurrent review decisions)
- Conduct on-the-job training for the hospital team to proactively drive hospital performance towards value-based care behaviors
- Ensure key performance metrics are on track and escalate issues in a timely manner to the AIA team for resolution
- Ensure a regular meeting cadence and utilization management activities are established and consistently executed, either virtually or through onsite hospital visits
Requirements
- Minimum Bachelor's degree in Nursing
- Minimum 5-7 years of clinical or claims assessor experience is preferred
- Advanced knowledge of ICD-10 and related clinical pathways
- Ability to interpret complex medical scheme rules with strong clinical reasoning and ability to challenge treatment plans constructively
- Familiar with insurance policy details and benefit schedules
- Understanding of hospital billing and tariffs with an analytical mindset and ability to interpret cost and utilization data
- Capable of stakeholder management across physicians, hospital administrators, and insurer teams
- High attention to detail in documentation and compliance
Important Details
- Criminal background check is required after completing the selection process and before joining the company
About the Company
AIA is an insurance provider.
