Casemix Manager
Core
Manage quality, costs, and compliance of BPJS patient services through case mix analysis, billing optimization, and regulatory adherence.
Role type
Senior operational manager (healthcare reimbursement & case mix)
Builds
Optimized reimbursement strategies and compliant care pathways for BPJS patients
Domain
Healthcare administration / Health insurance (BPJS) / Hospital operations
Deliverable
production ML models | product features | dashboards & analysis | client delivery | infrastructure | physical/clinical work
Required skills
Case mix analysis, BPJS regulation compliance, billing rate reconciliation, ICD/DRG coding proficiency, stakeholder collaboration, fraud prevention, data reporting accuracy, operational strategy execution
Preferred skills
Internal audit experience, quality project management, network building in health industry
Technologies
ICD, DRG, web applications for claims management
Responsibilities
Analyze BPJS patients by service unit to ensure positive internal referrals; Monitor billing rates vs. reimbursement amounts to identify profitable cases; Collaborate with medical teams to manage average length of stay (ALOS); Supervise prescription drug and consumable usage for BPJS patients; Resolve rejected claims with Internal Verifiers and specialists; Ensure compliance with BPJS regulations to prevent fraud; Provide updates on BPJS regulatory changes to clinical and administrative staff.
Seniority
Senior, hands-on IC