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Senior Manager - Pediatric Pre Authorization

Senior Manager - Pediatric Pre Authorization

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

Job Responsibilities

To ensure consistent & high-quality Pre-Authorization decisions in Internal Medicine , Pediatric , and Ob-Gyn specialties and related sub-specialties, particularly handling complaints related to regulator and group management, rejections, pending cases, and reworks. The decisions should align with BUPA values and incorporate the latest medical and legal liabilities, whether before release to providers or after initial decisions, thereby ensuring high customer safety, excellent customer experience, and regulatory compliance.

Patient Safety & Customer Experience

  • Re-adjudicate all rejection and pending cases before submission to providers to achieve Zero A & B QDI, focusing on their specialties.
  • Ensure medical decisions are justified and reversible if unjustified, prioritizing member health and safety.
  • Conduct internal quality checks to minimize medical liabilities from incorrect decisions.
  • Report critical or catastrophic decisions to the Pre-authorization Medical Manager.

High-Quality Medical Decision Making

  • Consistently apply medical decisions in line with BUPA clinical and practice guidelines.
  • Contribute to improving QDI scores, targeting Zero A & B QDI.
  • Investigate QDI cases assigned by the medical manager for detailed reporting.
  • Align medical decisions with common medical and market practices.
  • Identify gaps and trends in decision-making to improve processes.

    • Fraud & Abuse Prevention

  • Perform secondary checks on fraud, declaration, and anti-selection cases.
  • Ensure decisions comply with contractual and legal terms.
  • Report trends of abuse and over-utilization, especially related to specialties and sub-specialties.
  • Monitor and report policy and contractual violations.

    • Operational Excellence & Efficiency

  • Meet response time targets set by the business.
  • Contribute to achieving set targets and uphold BUPA’s promises to members.
  • Reflect high-quality decisions in QDI scores.

    • Customer Satisfaction

  • Handle VIP and high-value client requests proactively, especially regarding rejections and pending cases.
  • Participate in meetings with clients to resolve outstanding issues.

    • Business Support & Legal Risk Mitigation

  • Provide detailed, fact-based reports for complaints and legal / regulatory disputes.
  • Discuss high-value or critical cases with providers’ consultants.
  • Participate in activities supporting daily team operations, including system upgrades and research.
  • Collaborate with Sales and Customer Service teams to resolve complaints.

    • Capability Building

  • Engage in continuous medical education and knowledge dissemination within the team.
  • Participate in coaching and capability development activities.
  • Regularly update knowledge to meet evolving challenges.
  • Support team members with expertise, feedback, and problem-solving.

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    إنشاء تنبيه وظيفي لهذا البحث

    Senior Manager • Jeddah, Makkah Region, Saudi Arabia