Medical Care Assessor at Premier Hospital

Job Purpose

To review, assess and evaluate the medical care provided to patients to ensure appropriateness, cost-effectiveness, and adherence to clinical standards and policy guidelines. The role ensures that patient care meets the expected quality and complies with payers or regulatory requirements.

Main Duties and Responsibilities

• Ensure discharge TAT of less than 2 hours by assessing all patient medical records, treatment notes, and diagnostics results realtime to verify the necessity and appropriateness of care.
• Review inpatient and outpatient care and documentation for clinical accuracy and justification including diagnosis and insurance exclusions.
• Ensure treatments procedures comply with clinical guidelines.
• Evaluate insurance claims for completeness and correctness before approval.
• In liaison with care manager, liaise with insurance companies and other payers on clinical queries.
• Daily ward rounds to monitor standards of care delivered across different departments.
• Participating in clinical audits, hospital surgical package review meetings as well as contributing to overall care improvement programs and initiatives.
• Work with clinicians, billing teams, and claim units to align clinical and financial processes

Minimum Requirements/ Qualifications

• Diploma in Nursing from a recognized Institution.
• Valid practicing license.
• At least 2 years’ experience as a general nurse and 1 year in a similar role.
• Insurance training is an added advantage.
• Familiarity with Medical coding. (ICD-10, CPT)

Key Job Requirements

• Excellent communication and customer service skills.
• Good interpersonal skills and a team player.
• Flexible and can work under pressure with minimum supervision.
• Desire for personal development, improvement, and learning.