Background information about the job or company

Aga Khan University Hospitals in Karachi, Pakistan and Nairobi, Kenya are private, not-for-profit institutions providing high quality health care. The Main Hospitals serve as the principal sites for clinical training for the University's Medical Colleges and Schools of Nursing and Midwifery in Pakistan and East Africa. Our Vision of Aga Khan University Ho...

Job Purpose

To provide integrated hospital-based care management for corporate and insured patients by coordinating clinical care, client support, payer communication while serving as g as a liaison and coordinator to specific corporate payers And participating in formulating strategic plans for the future growth of AKUHN business.

Key responsibilities

Corporate Relationship and Business Support

• Maintain strong relationships with Corporate Care Managers & TPA’s.
• Conduct one-to-one engagement with the care managers.
• Identify gaps in service delivery and give feedback to management.
• Explore business development opportunities which the hospital can take advantage of.
• Monitor & evaluate referrals from these corporate.

Corporate Operational Guidelines

• Coordinate smooth execution of corporate operational guidelines.

Clinical Care, Coordination and Facilitation

• Coordinate care for scheme beneficiaries across inpatient, outpatient and diagnostic s
• Identifying high-risk patients (high cost, prolonged length of stay and re-admissions)
• Liase with clinicians to ensure timely service delivery aligned to patient needs and cover limits.
• Monitor the inpatient progress in the hospital.

Utilization/Financial management.

• Conduct utilization review for high cost and prolonged admissions
• Verifying itemized bills on daily basis and coordinating the same with the corporate care managers.
• Confirm benefits, limits and authorization to ensure appropriately and verify coverage and benefit with health insurer to ensure that the patient is appropriately billed.
• Coordinating availability of required services.

Advocacy Education Communication

• Advocates for the patients under specific schemes for needed services and educate accordingly, based on their limited cover.
• Coordinate communication between patients, clinicians, insurers and corporate partners.
• Resolve issues arising from patients, families, clinicians and payers.

Digital Health, Data & Reporting

• Utilize hospital information systems to track admissions, LOS, Utilization and discharges.
• Prepare periodic care management and utilization reports for management
• Support data- driven decision making for service improvement

Qualifications, Experience and Skills required:

• Diploma/bachelor’s degree in nursing
• Minimum 3 years nursing experience, both in acute / or critical care settings
• Minimum 2 years Care Management within insurance or corporate healthcare

Technical & professional competencies

• Hospital care coordination and utilization management
• Knowledge of clinical pathways and insurance benefit structures
• Understanding case-based costing added advantage
• Proficiency in hospital EHR and digital health systems

Personal characteristics & behaviors

• Strong communication skills & interpersonal skills
• Analytical and problem-solving ability
• Team player with resilience and patience
• Ethical decision making with high integrity

• Maintain strong relationships with Corporate Care Managers & TPA’s.
• Conduct one-to-one engagement with the care managers.
• Identify gaps in service delivery and give feedback to management.
• Explore business development opportunities which the hospital can take advantage of.
• Monitor & evaluate referrals from these corporate.
• Coordinate smooth execution of corporate operational guidelines.
• Coordinate care for scheme beneficiaries across inpatient, outpatient and diagnostic s
• Identifying high-risk patients (high cost, prolonged length of stay and re-admissions)
• Liase with clinicians to ensure timely service delivery aligned to patient needs and cover limits.
• Monitor the inpatient progress in the hospital.
• Conduct utilization review for high cost and prolonged admissions
• Verifying itemized bills on daily basis and coordinating the same with the corporate care managers.
• Confirm benefits, limits and authorization to ensure appropriately and verify coverage and benefit with health insurer to ensure that the patient is appropriately billed.
• Coordinating availability of required services.
• Advocates for the patients under specific schemes for needed services and educate accordingly, based on their limited cover.
• Coordinate communication between patients, clinicians, insurers and corporate partners.
• Resolve issues arising from patients, families, clinicians and payers.
• Utilize hospital information systems to track admissions, LOS, Utilization and discharges.
• Prepare periodic care management and utilization reports for management
• Support data- driven decision making for service improvement

• Strong communication skills & interpersonal skills
• Analytical and problem-solving ability
• Team player with resilience and patience
• Ethical decision making with high integrity
• Hospital care coordination and utilization management
• Knowledge of clinical pathways and insurance benefit structures
• Proficiency in hospital EHR and digital health systems

• Diploma/bachelor’s degree in nursing
• Minimum 3 years nursing experience, both in acute / or critical care settings
• Minimum 2 years Care Management within insurance or corporate healthcare
• Understanding case-based costing added advantage