Manager - Medical Claims Operations (Pipeline)
Full time
at Bupa Arabia
in
Saudi Arabia
Posted on January 24, 2025
Job details
To ensure that assigned provider’s Inpatient and Outpatient claims are medically & commercially adjudicated within the specified timeframe and within the targeted quality to achieve the business objective of ensuring that BUPA delivers high quality claim statements.
Adjudication
- Process all the daily batches of claims assigned in line with medical policy and Inpatient / Out-patient adjudication guidelines while using his/her medical background in conjunction with the instructed guidelines, day-in-day-out for smooth operation of business activity.
- Assure that each claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross-checking with the electronic claims data on Edge, reflecting the right decision for every claim on the operations system.
- Achieve daily target in terms of number of claims processed.
- Discuss all high profile/high value claims with the claims medical manager where the decision is difficult & well thought.
Quality
- Achieve required quality through achieving at least 95% accuracy level on monthly quality audits, in order to maintain the quality standard set for the job.
- Make sound medical decisions that minimize the opportunity to be challenged by providers, and consult with the medical manager where in doubt.
Fraud and Abuse Identification
- Report abnormal trends of provider practice for adjudicated claims where needed.
- Detect and escalate FWA cases to the concerned teams in line with Claims handling guidelines.
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