Job Description
We are looking for a Provider Engagement Officer in our Provider Relations department in Dubai. Provider Engagement Officer is responsible for representing the SAICOHEALTH as a case manager who coordinates cost-effective, high-quality medical care to help patients recover safely while minimizing financial risk for the insurance company.
The position manages the end-to-end coordination of escalated cases while maintaining strong, operational relationships with network doctors and hospital RCM teams. This position also serves as the primary medical matchmaker for high-cost, high-risk cases, guiding premium members to top-tier doctors and facilities when required. They build personal relationships with medical specialists and coordinate directly with hospital RCM to streamline pre-authorizations, billing, and complex discharge claims.
This position will be accountable for remote Disease Management program which includes reviewing patient-submitted health records to assess clinical status, deliver targeted health education, and drive self-management.
Main Responsibilities
- Review medical records of escalated cases (High-cost/ Complex/ Disputed Cases) to ensure requested treatments are medically necessary and align with policy coverage guidelines.
- Assess the case based on escalation reason \& resolve by taking up the discussion with internal departments and Providers.
- Identify high-quality, cost-effective care pathways which can be suggested to the member and the Provider for cost containment from an expensive treatment.
- Liaise with internal teams and the providers to negotiate additional discount on high-cost claims thereby finalizing single-case agreements (SCAs) with hospitals when requested.
- Maintain active, working relationships with hospital RCM staff, billing supervisors, and authorization departments to intervene in high-value claims or claim disputes to reach amicable, data-driven financial solutions and streamline high-cost claims.
- Collaborate with doctors, hospital Case Managers/ discharge planners and RCM teams to facilitate timely patient discharges to lower-cost care settings without compromising patient health and align clinical treatment plans with insurance authorization timelines.
- Serve as a direct, accessible, day-to-day contact for network doctors to resolve administrative queries, escalations, care variations or clinical process bottlenecks.
- Review complex or high-cost patient cases and actively recommend the most appropriate, cost-effective, high-quality doctors and facilities in the market as required.
- Provide support to patients with severe or complex diagnoses, ensuring seamless coordination and guiding them through the network targeted to minimize the cost and care delays while maintaining the quality.
- Act as the communication bridge between the patient, the treating physician, and the insurance company’s internal operations.
Qualifications:
- Bachelor’s degree in Medicine or Nursing (BSN).
Experience
- 5+ years of clinical experience. Experience in the Medical Insurance field combined with experience in insurance case management, utilization review, or hospital-side RCM/billing will be an added advantage
- Medical background / coding certification is a plus