Nurse (Pipeline)

Ensure medical cost control through managing benefit spend for Out Patient services ONLY, making sure that decisions are within defined SAMA & CCHI regulations, accepted guidelines and high quality common medical standards safe guarding the member's health & safety and in line with Bupa Values.

Key Accountabilities

• Adjudicate the Out Patient Cases based on common medical practice and inline with Bupa protocols and policy . 
• Ensure the decisions are according to the best medical standards and agreements' terms  & conditions in order to prevent abuse, fraud and overtreatment    
• Ensure member safety through working with High Quality of decision making with Zero QDI (Quality Demerit Index) A or B
• Ensure the medical decisions are consistent and proper implementation of the clinical and practice guidelines signed off by the organization    
• Ensure achiving of daily targets in terms of productivity & speed of response
• Ensure proper interpretation and usage of clinical skills
• Report all high Value calims as per agreed process with in Out Patient services
• Highlight and report fraud, abuse, and anti-selection    
• Apply terms and conditions of Bupa declaration policy in SMEs products
• Following CCHI policy terms and conditions
• 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
• Play active part in managing the Manual Request on Admin list within agreed KPIs

• Must be knowledgeable in MS Office package.
• Computer skills at advance level is must.
• Ability to conduct business in English language

Bachelor's degree in Nursing