Medical Case Manager
Il y a 2 mois
Description
**Goal**
Foyer Global Health was established in 2014 and is the specialist brand for globally mobile people from Luxembourg's leading insurance company Foyer.
Since its foundation, Foyer has become Luxembourg's primary insurance. Today, the European Union poses many new challenges while at the same time opening up a host of new opportunities.
In an increasingly competitive market, the Foyer Group remains true to its values: Trust, Excellence, Innovation, Integrity, Independence.
We are looking for a highly skilled and experienced Medical Case Manager to join our Partner and Medical Management team. In this role, your key responsibilities will include assessing medical risks for underwriting purposes and managing medical cases arising from insurance claims to ensure optimal outcomes for both clients and the insurer.
**Responsibilities**
**Medical Underwriting**
- Determine risk mitigation measures like exclusions, premium loadings, and denials.
- Ensure compliance with underwriting guidelines and regulatory requirements.
- Develop and maintain underwriting guidelines/processes for individual and group businesses.
- Act as an escalation point for medical risk assessments and explain risk mitigation measures clearly.
- Collaborate with stakeholders to gather necessary information for underwriting decisions.
- Support product development and provide internal training on medical matters.
- Develop and maintain underwriting literature (e.g., risk assessment documents, medical reports).
- Decide on pre-existing checks for facultative contracts and communicate consequences.
- Assist in planning and implementing MUW tools.
- Maintain underwriting statistics and provide reports as needed.
**Medical Case Management**
- Evaluate the medical necessity of treatments and ensure alignment with benefit coverage.
- Advise on cost reasonability, including guarantees of payment and client steering.
- Check for pre-existing conditions under Full Medical Underwritten and Moratorium contracts.
- Mitigate medical and provider fraud, preventing abuse and overutilization.
- Record savings from cost containment efforts.
- Provide support on emergency assistance cases and feedback management.
- Manage high-cost cases and provide necessary statistics to stakeholders.
- Provide medical training to operations, partners, and cross-functional teams.
- Develop internal medical guidelines and follow up on medical trends.
- Conduct renewal reviews of contracts to forecast expenses for individual cases.
- Assist in calculating savings and analyzing data for business reports.
- Hold regular meetings with medical professionals to exchange information and implement standardized rules.
**Knowledge and Skills**
- Medical Background: Preferably a qualified Medical Doctor or experienced Nurse with a health insurance background.
- Medical Knowledge: Comprehensive understanding of medical terminology, healthcare regulations, and medical coding.
- Certification: Preferred in Medical Underwriting and/or Case Management.
- Cost Containment and Fraud Prevention: Strong understanding of strategies and techniques.
- Risk Assessment: Ability to assess medical conditions, prognosis, and associated risks.
- Analytical Skills: Strong attention to detail and compliance.
- Communication: Excellent verbal and written skills in English; knowledge of German, French, and Spanish is an asset.
- MS Office and Data Analysis: Proficiency required.
**We offer**
By joining our Group, you will benefit from the following advantages, among others:
A multicultural, learning and innovative work environment,
Flexible working hours,
The benefits of a large group with the flexibility of an SME.
The possibility of homeworking
A company restaurant at preferential rates,
A gym with a trainer,
Hospitalization and group insurance
Concierge service
Languages English German French Spanish; Castilian Education Doctorate Experience 0+ years
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