Job Description

BMI Companies, part of BMI Financial Group, has nearly five decades of experience providing insurance and solutions for families worldwide. Specializing in high-quality Life Insurance, Health Insurance with global coverage, and Travel Assistance Plans, BMI is committed to innovating insurance products for the international community.

About the Role: The Case Manager supports patients with complex medical needs by coordinating care, facilitating communication among healthcare providers, and ensuring smooth transitions across care settings. They help patients navigate their healthcare options, manage high-cost or high-risk cases, and promote quality, cost-effective outcomes.

High-Cost Claims Review:

• Thoroughly review high-cost medical claims, including hospital stays, surgeries, specialized treatments, and procedures with significant financial impact, ensuring they meet medical necessities and policy guidelines.
• Analyze detailed medical records, treatment plans, and supporting documentation to determine if claims align with coverage policies and regulatory standards.
• Work closely with healthcare providers to obtain additional clinical information or clarification when needed for high-cost claims, ensuring complete and accurate review.

Catastrophic Claims Review:

• Review and assess catastrophic medical claims arising from severe illnesses, accidents, or other high-risk events that result in significant treatment needs and expenses.
• Collaborate with clinical teams and providers to evaluate the appropriateness of care for catastrophic claims, ensuring that the treatment plan is medically necessary and adheres to coverage policies.
• Ensure timely and accurate decision-making to support members' urgent needs in catastrophic situations while aligning with insurance guidelines and medical necessity criteria.

Unapproved Claims Management:

• Analyze and review claims that have been denied or unapproved to determine the cause for denial and explore opportunities for reconsideration, resolution, or appeal.
• Work with healthcare providers and internal teams to gather additional documentation, clarify details, and ensure that claims meet the necessary criteria for approval.
• Engage with members to explain the reasons for claim denial and assist in navigating the appeal process, ensuring that members receive necessary care within their insurance coverage.

Medical Necessity and Policy Compliance:

• Ensure that all reviewed claims, including high-cost, catastrophic, and unapproved claims, comply with the company’s medical necessity guidelines and coverage policies.
• Keep up to date with relevant healthcare regulations, policy changes, and best practices to ensure that claims decisions are consistent with industry standards.

Care Coordination & Member Advocacy:

• Act as an advocate for policy holders by guiding them through the approval process, explaining coverage details, and assisting with appeals or reconsiderations for denied claims.
• Collaborate with healthcare providers to identify potential alternatives to unapproved claims, ensuring that members receive medically necessary services in a timely and effective manner.

Documentation & Reporting:

• Maintain comprehensive, accurate, and up-to-date records of all claims reviewed, decisions made, and communications with healthcare providers, members, and internal teams.
• Create/Document/and maintain up to date the Standard Operating Procedures for the review process for high-cost, catastrophic, and unapproved claims thoroughly to ensure compliance with regulatory requirements and internal policies.

Claims Denial Prevention & Process Improvement:

• Identify trends in high-cost, catastrophic, and unapproved claims to help streamline the claims review process and prevent future claim denials.
• Provide feedback to management and claims teams regarding improvements in the review process to enhance accuracy, efficiency, and member satisfaction.

Collaboration with Cross-Functional Teams:

• Collaborate with claims processors, medical team, appeals committee, legal, and other internal teams to resolve complex high-cost, catastrophic, and unapproved claims in a timely manner.
• Act as a subject matter expert

Quality Assurance & Compliance Monitoring:

• Participate in quality improvement initiatives and audits to ensure claims are processed in accordance with established procedures and compliance standards.
• Review and assess the quality of care provided for high-cost and catastrophic claims, ensuring that members are receiving necessary and appropriate care within their insurance coverage.

Qualifications:

• Bachelor’s degree in nursing, Healthcare Administration, Medical Billing & Coding, or a related field. (Master’s degree or professional certifications preferred).
• RN certification in the state of practice.
• 2-3 years of nursing or medical practice experience.
• Case Management certification (PLUS).
• Certification in Case Management (CCM, ACM), or related claims certifications (e.g., CPC, CPMA) plus.
• Experience working with LATAM or International Private Medical Insurance (IPMI Industry)
• Minimum of 3 years of experience in case management and claims processing within the health insurance industry, with a focus on high-cost, catastrophic, or complex claims.
• Excellent communication, interpersonal, and customer service skills to interact effectively with members, providers, and internal teams.
• Ability to assess medical records, treatment plans, and claims to ensure medical necessity and appropriate care.
• Proficiency in using case management software
• Bi-lingual (English/Spanish) Fluent
• MUST RESIDE IN MIAMI, FL

Key Competencies

• Excellent customer service and communication skills.
• Problem-solving and analytical abilities.
• Cross-cultural sensitivity and organizational skills.
• Basic knowledge of MS Outlook, Word, Excel, and PowerPoint.

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