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Manager - Pre Authorization (Pipeline)

Manager - Pre Authorization (Pipeline)

BUPA ArabiaJeddah, Makkah Region, Saudi Arabia
منذ أكثر من 30 يومًا
الوصف الوظيفي

Jeddah, Saudi Arabia

Posted 2 days ago

Expires in 2 months

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 with BUPA Values.

Medical Cost & Service Management

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

High-Quality Medical Decision & Patient Safety

  • Maintain high-quality decision-making with Zero QDI (Quality Demerit Index) A or B.
  • Ensure medical decisions are consistent and based on clinical and practice guidelines approved by the organization.
  • Achieve high customer satisfaction in line with BUPA values and business strategy.
  • Meet daily productivity and response speed targets.
  • Properly interpret and utilize clinical skills.

    • Compliance to Policy and Regulation

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

    • Support & Contribute to Capability Building

  • Continuously upgrade knowledge and experience to meet challenges.
  • Offer professional help to team members.
  • Provide positive feedback and assist in problem-solving.

    • Skills

  • Clinical experience in General Practice / Emergency / Family Medicine.
  • Insurance experience is preferable.
  • Minimum 3 years of clinical experience excluding internship year.

    • Job Role : Medical, Healthcare, and Nursing

    #J-18808-Ljbffr

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