Case Manager

DUTIES AND RESPONSIBILITIES

1. Documentation & Gap Analysis

• Identify missing clinical data and communicate directly with the attending physician for timely completion.

• Validate clinical evidence to ensure services meet medical necessity criteria.

• Ensure case documentation accurately captures patient risk to justify the optimal case mix. 

2. Coding & Billing Optimization

• Review outpatient records to verify adherence to current E&M documentation guidelines.

• Prevent down-coding and missed revenue leakages by ensuring all services rendered are coded accurately.

3. Rejection & Denial Management

• Analyze the root causes of insurance claim rejections.

• Execute random file audits across different departments to identify trends and systemic errors.

• Provide actionable feedback and training to healthcare providers to prevent recurring denials.

4. Provider Education

• Advise doctors and departments on best-practice trends, optimal resource utilization, and controlling outlier expenses.

• Create training modules aimed at correcting recurring billing errors and documentation weaknesses

OSH ROLES AND RESPONSIBLITIES:

GENERAL:

1. Responsible for implementation of OSHAD-SF& NMCSH Al Ain Internal OSHMS/ OSHMS /EHSMS policies and procedures/SOP’s relevant to their department.

1. Should notify/report all OSHMS/EHSMS hazards, incidents, accidents and near misses within the premises of NMCSH Al Ain to their supervisor or department OSH Facilitator as per the incident reporting protocol of NMCSH Al Ain. 

1. Should familiarize them and comply with all NMCSH Al Ain OSHMS /EHSMS policies, standards and procedures that are relevant for their workplace.

1. Responsible to attend applicable department OSHMS /EHSMS training and follow NMCSH Al Ain policies and procedures. 

1. Responsible for taking reasonable care for their health and safety of persons and the Occupational   that may affect by the labor act or omissions at the workplace.

1. Responsible to wear all PPE’s provided to them.

1. Staff is not allowed to tamper or misuse any NMCSH Al Ain equipment’s and its property.

1. Should abide all safety instructions and signages within the premises of NMCSH-Al Ain.
   1. Responsible for following and complying with any specified OSH/EHS procedures associated to the task/job.

Specific:

1. Lead the development of appropriate OSH management system.

1. The ultimate responsibility for Occupational, Health and Safety within all facilities of NMCSH, Al Ain.

1. Shall allocate adequate resources for OSH management ( e.g. Budget , human resources, equipment’s) 

1. The GM approves and endorses NMCSH, Al Ain EHSMS/OSH Policies and Procedures/Programs /Plan. 

3.52   Sets and approves a clear OSH Policy for NMCSH, Al Ain. Ensure that the OSH policy is reviewed annually.

Duties & Responsibilities

Clinical Documentation & Coding

• Identify missing clinical documentation and liaise with attending physicians for timely completion.
• Validate clinical evidence to ensure compliance with medical necessity requirements.
• Ensure accurate documentation to support patient risk adjustment and optimal case mix.
• Review outpatient medical records for compliance with current Evaluation & Management (E&M) documentation guidelines.
• Ensure accurate coding of all services to prevent down-coding and revenue leakage.

Claims & Denial Management

• Analyze the root causes of insurance claim rejections and denials.
• Conduct random audits of medical records across departments to identify trends and documentation gaps.
• Recommend corrective actions to minimize recurring claim denials.
• Support billing optimization through accurate documentation and coding practices.

Provider Education & Quality Improvement

• Educate physicians and clinical departments on documentation and coding best practices.
• Develop and deliver training programmers to address recurring documentation and billing errors.
• Promote appropriate resource utilization and reduction of unnecessary costs.
• Provide continuous feedback to improve clinical documentation quality and coding accuracy.

Occupational Safety & Health (OSH) Responsibilities

General Responsibilities

• Implement and comply with OSHAD-SF and NMC Al Ain Occupational Safety & Health Management System (OSHMS/EHSMS) policies, procedures and SOPs.
• Report all hazards, incidents, accidents and near misses in accordance with the incident reporting protocol.
• Comply with all applicable OSHMS/EHSMS policies, standards and workplace procedures.
• Attend mandatory OSH/EHS training and apply safe work practices.
• Take reasonable care of personal health and safety and that of others affected by work activities.
• Wear and maintain all required Personal Protective Equipment (PPE).
• Protect hospital equipment and property from misuse or damage.
• Follow all safety instructions, warning signs and emergency procedures.
• Adhere to all task-specific OSH/EHS requirements.

Leadership Responsibilities

• Lead the development, implementation and continuous improvement of the Occupational Safety & Health Management System.
• Assume overall responsibility for Occupational Health & Safety across all NMC Al Ain facilities.
• Ensure adequate OSH resources, including budget, manpower and equipment.
• Approve and support OSH/EHS policies, procedures, programmers and annual plans.
• Establish and maintain a clear Occupational Safety & Health Policy and ensure it is reviewed annually.

• Medical or Allied Health graduate.
• Strong clinical training and healthcare background.
• Internationally recognised Medical Coding certification (e.g., CPC, CCS, CCS-P, CIC, COC, AHIMA or AAPC certification).
• Strong knowledge of medical coding, billing, clinical auditing, insurance approvals and revenue cycle management.
• Auditing certification or formal audit training is preferred.
• Minimum 5 years of clinical experience in a hospital setting.
• Minimum 2 years of supervisory or team leadership experience.
• Excellent analytical, problem-solving and communication skills.
• Proficient in EMR/HIS systems, medical documentation standards and coding guidelines (ICD, CPT/HCPCS, as applicable).
• Strong organisational skills with the ability to manage multiple priorities while maintaining accuracy and compliance.