إرفاق
وصف الوظيفة
Job Description
To ensure that assigned provider’s Inpatient claims are medically & commercially adjudicated onsite the Hospital within the specified timeframe and within the targeted quality to achieve the business objective of ensuring that BUPA delivers high quality claim IP statements.
Adjudication
- Review and Process all the IP Cases/ claims onsite the hospital in line with medical policy, line items, invoice and Inpatient adjudication guidelines while using his/her medical background in conjunction with the instructed guidelines, day-in-day-out for smooth operation of business activity.
- Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse, fraud and overtreatment.
- Assures 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, Hospital System, Hospital Managment and reflecting the right decision for every claim on the operations system.
- Achieve daily target in terms number of claims.
- Discusses all high profile/high value claims with the claims onsite manager where the decision is difficult & well thought.
- Managing the IP Claims issues with the Hospital Management to assure collaborative partnership relationship.
Quality
- To achieve required quality through achieving at least 95% accuracy level on daily quality audits, in order to maintain the quality standard set for the job.
- Makes sound medical decisions that minimize the opportunity to be challenged by providers, and consults with the medical manager where in doubt.
Fraud and abuse identification
- Reports abnormal trends of provider practice for adjudicated claims where needed.
- Detects and escalates FWA cases to the concerned teams in line with Claims handling guidelines.
- Monitor the identified providers' trends, on a monthly basis.
Support & contribute to capability building
- 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.
Workplace and Roving function
The onsite doctor will adjudicate the claims onsite at the assigned hospitals on a daily base, based on the volume and flow of cases, roving between the assigned hospitals and being present at the hospital whenever needed.
المهارات
Skills
- Clinical Experience.
- Medical Insurance Experience.
Education
MBBS (Bachelor of Medicine & Surgery
تفاصيل الوظيفة
المرشح المفضل
Bupa Arabia
Bupa Arabia is a healthcare insurance company based in the Kingdom of Saudi Arabia. We are an associate business of Bupa Group, which is a global healthcare company with an international reach that extends across multiple business operations, practices, and resources.
Founded in October 1997, Bupa Arabia was initially established through a partnership between Bupa Global International and Nazer Group, with the key focus to provide health insurance services with high quality and competitive prices, while ensuring a distinctive experience for customers. Bupa Arabia has since evolved into a fully Saudi-owned and operated company. Our transformation from a joint venture into a publicly traded company on the Saudi Stock Exchange occurred in 2008, as we made 40% of our shares available to the public during our Initial Public Offering (IPO).
As a subsidiary of the global Bupa Group, we draw upon international expertise while maintaining a profound understanding of local healthcare requirements and regulations. This allows us to offer comprehensive healthcare insurance solutions tailored to the unique needs of the Saudi Arabian market.
Bupa Arabia prides itself on its commitment to the wellbeing and development of its employees, providing them with the same standard of care, support, and professionalism that it expects to be delivered to its customers.
Our core values shape every aspect of our work and culture:
Commit – Own it with accountability and urgency.
Collaborate – Win together through cross-functional synergy.
Care – Put people first, both employees and customers.
