EXECUTIVE, CASE REVIEW

Job Description:

Case Review & Clinical Documentation Verification

•  Review all insurance queries, AUC cases, and clinical documentation received from insurers.
• Coordinate with consultants to obtain complete, accurate, and timely medical replies to insurance companies.
• Verify doctors' responses for completeness, accuracy, medical appropriateness, and compliance before submission.
• Return incomplete or inaccurate replies for correction prior to insurer submission.
• Ensure all supporting documents required by insurers are attached before submission.
• Maintain complete documentation of all correspondence with consultants and insurers.

Professional & Hospital Fee Verification

• Verify that all Professional Fees (PF) and Hospital Fees (HF) are charged according to approved hospital charge codes, Fee Committee decisions, and charging policies.
• Review billing discrepancies, unusual charging patterns, and fee-related concerns.
• Escalate unethical or non-compliant charging practices to the Head of Business Operations and Hospital Fees Committee.
• Support periodic reviews of hospital charge codes and charging governance.

 Amount Under Clarification (AUC) Management

• Register, monitor, and track all AUC cases from receipt until closure.
• Follow up with consultants and insurers to ensure timely resolution of outstanding AUC cases.
• Maintain an updated AUC tracking database by consultant, insurer, specialty, and ageing.
• Prepare monthly AUC performance reports for Management, Hospital Fees Committee, and Group Business Office.
• Identify recurring trends and recommend corrective actions to reduce AUC occurrences.

Insurance Claim Coordination

•  Respond to insurance queries relating to medical reports, billing clarification, coding, and treatment justification.
• Liaise with insurers, TPAs, consultants, Medical Records, Nursing, Billing, and Admissions to resolve claim-related issues.
• Ensure all insurer requests are responded to within the agreed Service Level Agreement (SLA).
• Support appeals for rejected or partially approved insurance claims where required.

Revenue Assurance & Billing Compliance

• Review discharged patient bills requiring clarification before final submission.
• Ensure all hospital and professional charges are accurately captured before claim submission.
• Identify potential revenue leakage arising from missing charges, incorrect coding, or documentation gaps.
• Recommend corrective actions to improve billing accuracy and claim acceptance.

Turnaround Time (TAT) Management

• Ensure all AUC cases and insurance queries are responded to within 14 working days or within insurer SLA requirements.
• Escalate overdue cases to the respective consultant, Head of Service, or Head of Business Operations.
• Monitor departmental turnaround time performance and recommend process improvements.

 Key Performance Indicators (KPIs)

•  ≥95% AUC cases resolved within 14 working days.
• ≥95% insurer queries responded to within SLA.
• ≤5% overdue AUC cases.
• Zero missed follow-up for outstanding insurance queries.

7.     Reporting & Audit

• Prepare monthly reports on AUC status, ageing analysis, consultant performance, insurer trends, and revenue impact.
• Support internal and external audits by providing complete case documentation and billing records.
• Maintain accurate records in accordance with hospital policies, insurer requirements, and regulatory guidelines.

Compliance & Quality Improvement

• Ensure compliance with hospital policies, Standard Operating Procedures (SOPs), insurer requirements, PDPA, and healthcare regulations.
• Participate in billing quality improvement initiatives, charge governance reviews, and revenue optimisation projects.
• Provide education and feedback to consultants and relevant departments on documentation and billing requirements.

Other Duties

• Collaborate with Admissions, Billing, Credit Administration, GL Verification, Medical Records, Nursing, and consultants to facilitate efficient insurance claim processing.
• Perform any other duties or special projects assigned by the Head of Business Operations or Hospital Management.
• Comply with all hospital policies, procedures, and instructions issued by the organisation and Head of Service.

Requirements:

Education: Minimum Diploma in any related field

Knowledge and Experiences:

• Minimum 2 years relevant experience in hospitality environment.
• Excellent interpersonal & communication skills.
• Excellent in both written and verbal (Bahasa Malaysia/English)
• PC Literate

  Special skills required

• A self-starter with initiative and ability to work independently.
• Effectively interacts at all levels.
• Works beyond normal hours in support of projects or other assignments.
• High level of integrity, honest, trustworthy and able to maintain confidentiality.
• All duties are performed in a warm and courteous manner.

  Personal attributes

• High level of integrity, honesty, trustworthiness, and ability to maintain confidentiality.