Utilization Management

Overview

The Utilization Management (UM) & Claims Manager is responsible for overseeing the day-to-day operations of both the utilization management and medical claims review processes. This role ensures that all inpatient, outpatient, emergency, elective, and dental procedures are reviewed based on medical necessity, appropriateness, benefit coverage, and member eligibility. The manager will also oversee claims processing workflows, ensuring accuracy, compliance with service-level standards, and alignment with clinical and contractual requirements.

The role involves team management, process optimization, clinical review collaboration, and strong coordination with customer service, provider relations, finance, and technology teams.

Key Responsibilities :

Utilization Management

• Oversee prior authorization and concurrent reviews for inpatient, outpatient, emergency, elective, and dental treatments based on medical necessity and benefit eligibility.
• Conduct medical reviews and ensure all decisions comply with international clinical guidelines and client-specific protocols.
• Coordinate inpatient case management, discharge planning, and continuity of care with hospitals and providers.
• Work closely with the Medical Director and UM leads to ensure clinical appropriateness and alignment with company policies.
• Ensure turnaround times and service level standards are met for all authorizations and medical reviews.
• Issue guarantee letters for approved inpatient admissions and finalize payment responsibilities prior to discharge.
• Monitor utilization patterns and contribute insights to product development and cost-containment strategies.

Claims Management

Team and Process Management

Cross-Functional Support

Educational Background

Job Type : Full-time

Pay : From RM8,500.00 per month

Benefits :

Education :

License / Certification :

Work Location : In person