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Job Description
To ensure that all Pre-Auth decisions taken by the team is as per defined policy guidelines that are compatible with high medical standards that help in safe-guarding member’s health & safety & also being compliant with TPA, CHI Regulations and BUPA values.
Key Accountabilities:
Medical cost & Service Management:
- Ensure all cases adjudicated by the team is based on common medical practice and aligned with BUPA protocols and policy .
- Ensure the decisions taken by the team are according to the best medical standards and agreement’s terms & conditions in order to prevent abuse, fraud and overutilization.
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 compliance to TPA and CHI regulations during medical adjudication.
Operation excellence:
- Process improvement initiatives to achieve excellence
- Lead the team and deliver service strategy agenda
Efficiency management:
- Ensure that the adjudicating requests for his team is as per accepted medical practice and as per Bupa medical protocol thereby securing patient safety from medical abuse.
- Ensure achieving the daily Targets in term of productivity and speed answer for adjudicated requests
- Ensure proper interpretation and usage of clinical skills
- Improve decision making skills on individual level
Capability Building & People Management:
- Ensure and facilitate goal setting; manage and constantly review individual performance
- Provide regular feedback, coaching and development
- Motivate, empower and enable direct reports by providing the necessary tools and support
Support the business & communicate effectively:
- Discuss & report the requested reports by the clients with involved parties
- Take active part in complaint management and communicate effectively (inter/intra department)
- Participate effectively in weekly / monthly meetings
- Manage any crises effectively based on already set business continuity plan
Compliance to policy and Regulation:
- Ensure applying terms and conditions of Bupa declaration policy in SMEs products
- Report all high Value claims as per agreed process
- Highlight and report fraud, abuse, and anti-selection
- Following CHI policy terms and conditions
Skills
- Postgraduate in Medicine / Masters in Business Studies, preferable .
- 5 years experience at least in medical field ( Hospital practicing ) or at insurance field
- Language (English) and computer skills
- Crabapple of producing efficient reports and presentations
- Clinical experience as General Practitioner / Emergency / Family Medicine
- Medical insurance practice
- Leadership and Analytical skills
- Crisis Management
- 3 years in medical insurance/administrative field
- 2 years in medical /clinical field practice
Job Details
Preferred Candidate
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.