Senior Registrar - OBGyn Pre Authorization

Overview

To ensure consistent & high quality Pre-Authorization decisions in

Internal Medicine ,

Pediatric

and

Ob- Gynae

specialties and related sub specialties , (particularly complaints related to regulator and big groups managements either related to rejections, pending and reworks) that are in line with BUPA values & with the latest most updated applied medical and legal liabilities for the organization ,either before being released to the providers or after the initial conveyed decision , thereby enabling high customer safety , excellent customer experience and regulatory compliance Patient safety & customer experience

Ensure patient safety & better customer experience by re-adjudicating all the rejections & pending cases before being sent to the providers to achieve Zero A & B QDI , for the cases concentrated to their specialities but not limited to. Ensure the medical decision is justified, and the ability to reverse the decisions whenever it is unjustified, effecting the member health and safety Secure the internal quality check and minimize the medical liabilities due to wrong or unjustified decisions related to their specialities and subspecialities Reporting the critical or catastrophic decisions to the Pre-authorization Medical Manager Ensure high quality medical decision

Ensure the medical decisions are consistantly implemented and in accordance with BUPA clinical & practice guidelines Actively contribute in improving the QDI scoring (Achieiving the target of Zero A & B QDI) Investigate QDI cases assigned to them by the pre-authorization medical manager for detailed reports Ensure the medical decision to be in line with the common medical and market practice Highlight users' gaps and inconvenience trends regarding the medical decision making Secure the organization against Fraud & abuse

Provide second check on fraud , declaration and anti-selection cases Secure the decision malking is in line with contractual and legal terms & conditions Highligh and report abusive and over-utilizing trends to the Pre-auth, Business and medical managers secially related to their specialities and sub specialities. Track and report groups', members'and providers' trends of breaching policy / contractual terms & conditions Highlight and report policy & contractual violation (if any) to the pre-authorization business manager & medical manager Achieve operational excellence and improving adjudication efficiency

Achieve the response time targeted by the business Achieve the contribution target set by the business Ensuring delivering BUPA promise to the members Ensuring the high quality medical decision to be reflected on achieving the QDI target set by the business Secure and achieve customer satisfaction

Handle the VIP and hi-value client requests that are to be reported to him whenever a rejection or pending is most likely, and ensure achieving the response time targeted by the business Take active part in meetings with customers to solve any outstanding issues resulted from execution of the pre-authorization process Support the business and secure it from commercial damage and / or legal liabilities

Assess and submit detailed reports that are fact based and on correct medical and scientific back ground for all complaint cases, regulatory and / or legal disputes related to their sepcialities and sub specialities Discuss the high value claims and / or critical cases with the providers’ consultants related to the specialitties and subspecailities. Take active part in all activities related to smooth running of the daily work of the team including system upgrade, reporting and research May participate and / or serve on unit’s committees and task forces Maintain full cooperation with colleagues in Sales and Customer service departments by providing them with all the support needed to solve complaints arising as a result of preauthorization process Support & contribute in capability building

Participate actively in the Continuous medical programs of the pre-authorization department to disseminate his medical knowledge and experience to the pre-authorization team members specifically related to their specialties and sub specialties but not limited to . Participate actively in the coaching and capability building programs and activities of the pre-authorization department Constantly upgrade his knowledge and experience in order to meet challenges Offer professional help to the rest of his team members ,provide positive feedback and help in solving problems

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