Utilization Review Nurse

As an Utilization Case Manager (UCM) representing AIA, you will serve as a critical clinical liaison with our partner hospitals. Your role is to ensure optimal patient journey and cost-effective care delivery by coordinating with the hospital, guiding treatment pathways, and enforcing insurer protocols to improve clinical and financial outcomes aligned with AIA’s quality and efficiency standards.

This role is ideal for a clinical professional who excels in communication, patient advocacy, and data-driven care coordination. As an UCM, you can advise thru communication via hospital personal on the available benefits and coverage they have, optimizing for the treatment they need.

Main Responsibilities:

• Validating and providing recommendations in real-time on the appropriateness of hospital admissions for simple disease and day surgery eligible procedures to capture efficiency savings from conversion to right care setting
• Validating appropriateness of length of stay on a daily basis for eligible simple disease and other upcoming conditions in scope in accordance to AIA’s LOS benchmark
• Discussing member benefits with the admitting doctor and nurse for to optimize treatment plan based on the member’s benefit scope
• Facilitating AIA-related requests raised from the hospital to improve overall insurer/provider/member experience (e.g., coordinating pre-auth and concurrent review decisions)
• Conduct on the job training to hospital team to proactively drive hospital performance towards value-based care behaviors
• Ensuring key performance metrics are on-track and escalate issues in timely manner to AIA team for resolution
• Ensure a regular meeting cadence and utilization management activities are established and consistently executed, either virtually or through onsite hospital visits

Qualifications:

• Minimum qualification of Bachelor degree in Nursing
• Minimum 5-7 years of clinical or claims assessor experience is preferred
• Advance knowledge on ICD-10 and related clinical pathways
• Ability to interpret complex medical scheme rule with strong clinical reasoning and ability to challenge treatment plans constructively
• Familiar with insurance policy detail and benefit schedule
• Understanding of hospital billing and tariff with analytical mindset with ability to interpret cost and utilization data
• Capable at stakeholder management across physicians, hospital admins, and insurer teams
• High attention to detail in documentation and compliance

In accordance with recruitment policy and hiring standard of AIA (Thailand) Company Limited, after completing the selection process, you are required for criminal background check before joining the company. Your criminal record information will be retained according to the PDPA policy of the company. As per attached link [https://www.aia.co.th/th/about-aia/privacy/candidate]