Manager - Medical Pre Authorization
دوام كامل
في Bupa Arabia
في
Saudi Arabia
نُشرت يوم February 20, 2025
تفاصيل الوظيفة
Rabigh, Saudi Arabia Posted 2 days ago Expires in 5 days 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.
Medical Cost & Service Management
- 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.
High Quality Medical Decision & 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.
- 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 & Contribute in Capability Building
- Constantly upgrade knowledge and experience in order to meet challenges.
- Offer professional help to the rest of the team members.
- Provide positive feedback and help in solving problems.
Skills
- Clinical experience in General Practitioner / Emergency / Family Medicine.
- Insurance experience preferable.
- Minimum 3 years of clinical experience excluding internship year.
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