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Jeddah , Saudi Arabia
Posted 2023/09/28 08:46:11
Expires 2023-11-01
Ref: JB1100039593
Job Description
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
Skills
- Must be knowledgeable in MS Office package.
- Computer skills at advance level is must.
- Ability to conduct business in English language
Education
Bachelor's degree in Nursing
Job Details
Job Location
Jeddah , Saudi Arabia
Job Role
Medical, Healthcare, and Nursing
Preferred Candidate
Career Level / Band
Mid Career
Years of Experience
Min: 1
Residence Location
Saudi Arabia
Minimum Degree
Bachelor's degree