Care Manager at Bristol Park Hospital

Responsibilities
Key Responsibilities

• Coordinate all inpatient and outpatient pre-authorization requests, extensions, and undertakings with payers.
• Ensure timely submission, follow-up, and approval of pre-authorizations and extensions within required turnaround times.
• Liaise with insurers, brokers, patients, and internal clinical teams to provide timely communication and clarification.
• Validate and manage undertakings, guarantee of payments, and financial exposures for admissions and specialized procedures.
• Ensure accuracy, completeness, and compliance of documentation and medical reports required by payers.
• Review service validity, membership, and benefit coverage against payer rules and clinical standards.
• Maintain accurate and structured records of authorization activities, including high-value cases.
• Coordinate inward and outward referrals, ensuring complete documentation and seamless continuity of care.
• Monitor trends, generate reports (daily, weekly, monthly), and identify gaps for continuous improvement.
• Support interdepartmental communication to enhance timely service flow and customer experience.
• Conduct capacity building for staff on appropriate billing and care coordination.
• Uphold compliance with regulatory, ethical, and care quality standards.

Qualifications

Qualifications & Experience

Essential

• Bachelor’s Degree in Nursing, Clinical Medicine, or related healthcare field.
• Minimum 3 years’ experience in:
• Care coordination / Case management
• Utilization review
• Medical insurance liaison
• Claims processing
• Admission and discharge management
• Experience working with insurers, payers, and TPAs.
• Proven ability to interpret medical documentation, reports, and treatment plans.

Desirable

• Certification in Case Management, Utilization Management, or Health Insurance.
• Experience in referral coordination or clinical pathways.
• Experience in a multi-specialty hospital environment.
• Experience using HIS/EMR authorization modules.