Medical Case Manager

at  Healix Group of Companies

MEDICAL CASE MANAGER

We have two openings for a Medical Case Manager position at Healix in either our Esher or Bristol-based office.
Reporting to the Clinical Lead, the post holder will provide a confident, knowledgeable and efficient service to Healix members, via telephone (inbound and outbound) and email, managing claims and signposting to appropriate services included in the scheme benefits.
This role is more than simply assessing member claims, the post holder will be expected to use their clinical knowledge to ensure members feel supported during treatment, guiding, supporting and signposting to ensure best outcomes and service.

We are looking for candidates who meet the following criteria:

• Registered RN, RMN or allied health professionals with an active HCPC registration.
• Broad range of acute clinical experience.
• Ability to deal calmly and professionally face to face or remotely with stakeholders at all levels.
• A resilient manner and excellent communication skills, a mature confident approach and the ability to interact with individuals who are undergoing complex treatment and may be distressed, anxious or unhappy with the outcome of a cover decision.
• Ability to use clinical and commercial skills to carefully balance member experience, treatment eligibility and cost effectiveness.
• Awareness of own limitations, recognising when it is appropriate to escalate cases to the Head of Clinical Service for review.

KEY ACTIVITIES/RESPONSIBILITIES (WHAT YOU’LL DO):

• Support members throughout their treatment pathway to ensure clinically appropriate and cost-effective outcomes.
• Manage a caseload, proactively guiding members to the most appropriate services, signposting to alternative treatments and pathways where appropriate.
• Proactively manage queries from colleagues and providers, both remotely and in person using appropriate case management software.
• Provide clinical support where required for the review of eligibility requests including treatment authorisation and declines in cover.
• Work proactively with providers to support timely hospital discharge and cost appropriate treatment.
• Maintain up to date and accurate knowledge of current best practice and clinical guidelines to ensure all decisions made are clinically appropriate.
• Use clinical skills to make decisions on highly complex treatment in relation to high cost and complex claims, including appropriate length of stays for inpatient admissions, authorisation of complex cancer drug regimes and medical auditing of invoices.
• Correctly interpret internal policies and guidelines, using correct coding systems for accurate gathering of data.
• Work closely with the Nurse Consultant to accurately project likely treatment costs per scheme year and provide this information to relevant stakeholders as per standard operating procedures.