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Manager - Pre Authorization (Pipeline)

Manager - Pre Authorization (Pipeline)

Bupa ArabiaAl Khobar, Eastern Province, Saudi Arabia
14 منذ ساعات
الوصف الوظيفي

Overview

To ensure medical spend (In-Patient & Out-Patient services) is controlled by ensuring that pre-authorization decisions are within defined SAMA & CCHI regulations, accepted guidelines and high-quality medical standards, safeguarding the member's health & safety and aligned to BUPA Values

Responsibilities

  • Adjudicate the cases (In-Patient & Out-Patient) based on common medical practice and in line with Bupa protocols and policy.
  • Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse, fraud and overtreatment

Quality and Patient Safety

  • Ensure working with high quality of decision making with Zero QDI (Quality Demerit Index) A or B
  • Ensure the medical decisions are consistent and are implemented based on clinical and practice guidelines signed off by the organization.
  • Ensure high customer satisfaction in line with BUPA values and business strategy

    • Efficiency

  • Ensure achieving the daily targets in terms of productivity & speed of response.
  • Ensure proper interpretation and usage of clinical skills

    • Compliance to policy and Regulation

  • Report all high value claims as per agreed process.
  • Highlight and report fraud, abuse, and anti-selection.
  • Apply terms and conditions of BUPA declaration policy in SME products.
  • Follow CCHI policy’s terms and conditions

    • Support & capability development

  • 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

    • Qualifications

  • Valid Saudi Commission
  • Clinical experience in General practitioner / Emergency / Family Medicine
  • Insurance experience preferable
  • Minimum 3 years of clinical experience excluding internship year.

    • Education

    Medicine and Surge

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    إنشاء تنبيه وظيفي لهذا البحث

    Manager • Al Khobar, Eastern Province, Saudi Arabia