Clinical Case Manager – US Healthcare

This is a fully remote position, open to applicants in South Africa.

📋 Description

• Oversee the complete management of US healthcare cases for clients in Skilled Nursing Facilities, post-acute care, and revenue cycle management.

• Evaluate clinical documentation to determine medical necessity and appropriate level of care.

• Handle authorizations for inpatient care and Skilled Nursing Facilities.

• Coordinate authorizations and claims with providers, payers, and patients effectively.

• Manage US healthcare claims from initiation to resolution, including handling denials, rejections, and appeals.

• Act as a liaison with Medicare, Medicaid, and commercial payers.

• Ensure precise medical billing and coding, utilizing ICD-10 and CPT codes.

• Maintain compliant case notes and documentation throughout the process.

• Collaborate with clinical, administrative, and finance teams to enhance operational effectiveness.

• Ensure adherence to HIPAA regulations.

• Utilize MS Office for reporting and tracking purposes.

• Efficiently manage a high volume of emails with professionalism and accuracy.

⛳️ Requirements

• Mandatory healthcare experience; candidates lacking this will not be considered.

• 1 to 3 years of experience in the healthcare field.

• Familiarity with ICD-10 and CPT coding systems.

• Demonstrated experience in case or account management.

• Proven track record in Skilled Nursing Facilities or post-acute care environments.

• Experience in processing inpatient authorizations is essential.

• Background in clinical review is required.

• Experience in medical billing is necessary.

• A fixed fibre line with a minimum upload and download speed of 25 Mbps is required.

• Capability to support a wired Ethernet connection.

• A reliable power backup solution to handle load shedding and power outages is necessary.

• Availability to work during USA hours from Monday to Friday, 9 am to 6 pm EST.

• Advantageous: A clinical background in Nursing or Allied Health.

• Advantageous: Experience in sub-acute, SNF, hospice, or hospital settings.

• Advantageous: Exposure to US healthcare BPO operations.

• Advantageous: Strong skills in documentation and reporting.

• Advantageous: Experience with US insurance payers.

🏝️ Benefits

• Work-from-home arrangement.

• Compensation for working on all South African public holidays in accordance with BCEA.