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Job Description
To ensure consistent & high-quality pre-authorization decisions (particularly rejections, pending, and reworks) that are in line with BUPA values & with the least medical and legal liabilities for the organization, before being released to the providers, thereby enabling high customer safety & excellent customer experience
Patient Safety & Quality Medical Decision:
- Ensure the medical decisions are consistently implemented and in accordance with BUPA clinical & practice guidelines
- Actively contribute in improving the QDI scoring (Achieving the target of Zero A & minimal B QDI)
- Investigate QDI cases assigned to them by the pre-authorization medical manager for detailed reports
- Ensure the medical decision to be in line with the common medical and market practice
- Highlight users' gaps and inconvenience trends regarding the medical decision making
Fraud, Abuse & Compliance Safeguarding:
- Provide second check on fraud, declaration and anti-selection cases
- Secure the decision making is in line with contractual and legal terms & conditions
- Highlight and report abusive and over-utilizing trends to the Pre-auth, Business and medical managers
- Track and report groups', members 'and providers' trends of breaching policy /contractual terms & conditions
- Highlight and report policy & contractual violation (if any) to the pre-authorization business manager & medical manager
Operational Excellence & Adjudication Efficiency:
- Achieve the response time targeted by the business
- Achieve the contribution target set by the business
- Ensuring delivering BUPA promise to the members
- Ensuring the high-quality medical decision to be reflected on achieving the QDI target set by the business
Customer Satisfaction & Stakeholder Engagement:
- Ensure the medical decision is justified, and the ability to reverse the decisions whenever it is unjustified, effecting the member health and safety
- Reporting the critical or catastrophic decisions to the Pre-authorization Medical Manager
Business Support & Capability Building:
- Participate actively in the Continuous medical programs of the pre-authorization department to disseminate his medical knowledge and experience to the pre-authorization team members.
- Participate actively in the coaching and capability building programs and activities of the pre-authorization department
- 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
Skills
- Medical clinical practice
- Medical insurance practice
- Computer skills are must
- University Degree ( MBBS , MBBCH ) in medicine and surgery
- Post graduate Medical Master Degree or Medical Diploma.
- 3 years experience at least in medical field (Hospital practicing)
- Language (English) and computer skills
- At least 3 years of medical / clinical field practice
- At least 1 year of insurance / administrative 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.