Specialist

Nice to know

Responsible for managing the pre‑arrangement process, including pre‑approval for medical procedures and surgeries, to support the company’s hospital network. The position ensures accurate assessment of medical necessity and effective cost containment, particularly for provider package‑price procedures. This role helps ensure customers receive appropriate benefit management aligned with customary pricing, while contributing to overall treatment cost control and business cost savings.

Your Day at Allianz Ayudhya

1. Reviews of claims and medical reports (medical indication assessment)

• Verify the eligibility of the claim by using and applying medical knowledge to pre-arrangement cases.
• In case of medical issues such as medical necessity for the procedures have to consult medical consultant team.
• Applies all medical necessity guidelines (Thai Medical Practice Guidelines), determine coverage and apply all cost containment measures.
• Sending the criteria checklist to consultant doctor
• The conclusion and issuing the confirmation letter to hospital network within SLA (3 days) (complete documents)
• Control the cost-effectiveness of medical care and ensure that any new clinical procedures, drugs or technology are appropriate and safe for our customers.
• Study and understand L&H policy & coverage to apply pre-arrangement part.
• Coordinate with Internal team such as medical team, Claim team and External team such as utilization nurses from the hospital.
• Summary monthly report in assigned area.

2. Collaboration process with Provider management team, Health Concierge, Health Solutions step as below;

• Screening the case which meets the criteria for collaboration project such as Preferred hospital, Premium Public hospital or package.
• Package price checking of each provider.
• Provider (Hospital) negotiation.

3. Detects suspicious, fraud or abuse claim from hospital network and refer to Retrospective review and Concurrent review team.

4. Process Coding (ICD codes-ICD9, ICD10) based on medical procedures and the claim process.

Must Have

• Degree in Nursing Science
• Minimum 3 years in nursing expirience.
• Nurse in critical units such as IPD (Surgery) ICU, OR and Fax Claim will be an advantage.
• Experience in insurance related topics