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Job Description
To ensure consistent & high quality Pre-Authorization decisions in Internal Medicine, Pediatric and Ob- Gynae specialties and related sub specialties , (particularly complaints related to regulator and big groups managements either related to rejections, pending and reworks) that are in line with BUPA values & with the latest most updated applied medical and legal liabilities for the organization ,either before being released to the providers or after the initial conveyed decision , thereby enabling high customer safety , excellent customer experience and regulatory compliance
Patient safety & customer experience
- Ensure patient safety & better customer experience by re-adjudicating all the rejections & pending cases before being sent to the providers to achieve Zero A & B QDI , for the cases concentrated to their specialties but not limited to.
- Ensure the medical decision is justified, and the ability to reverse the decisions whenever it is unjustified, effecting the member health and safety
- Secure the internal quality check and minimize the medical liabilities due to wrong or unjustified decisions related to their specialties and subspecialities
- Reporting the critical or catastrophic decisions to the Pre-authorization Medical Manager
Ensure high quality medical decision
- Ensure the medical decisions are consistantly implemented and in accordance with BUPA clinical & practice guidelines
- Actively contribute in improving the QDI scoring (Achieiving the target of Zero A & 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
Secure the organization against Fraud & abuse
- Provide second check on fraud , declaration and anti-selection cases
- Secure the decision malking is in line with contractual and legal terms & conditions
- Highligh and report abusive and over-utilizing trends to the Pre-auth, Business and medical managers secially related to their specialities and sub specialities.
- 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
Achieve operational excellence and improving 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
Secure and achieve customer satisfaction
- Handle the VIP and hi-value client requests that are to be reported to him whenever a rejection or pending is most likely, and ensure achieving the response time targeted by the business
- Take active part in meetings with customers to solve any outstanding issues resulted from execution of the pre-authorization process
Support the business and secure it from commercial damage and/or legal liabilities
- Assess and submit detailed reports that are fact based and on correct medical and scientific back ground for all complaint cases, regulatory and/ or legal disputes related to their sepcialities and sub specialities
- Discuss the high value claims and/or critical cases with the providers’ consultants related to the specialitties and subspecailities.
- Take active part in all activities related to smooth running of the daily work of the team including system upgrade, reporting and research
- May participate and /or serve on unit’s committees and task forces
- Maintain full cooperation with colleagues in Sales and Customer service departments by providing them with all the support needed to solve complaints arising as a result of preauthorization process
Support & contribute in 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 sepcifiaclly related to their specailities and sub specialities but not limitied to .
- 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/ knowledge
- Computer skills are must
- 3 years experience at least in medical field ( Hospital practicing ) in the concerned speciality
- Valid License as Senior registrar or specialist minimum in Internal medicine or Pediatric or Ob-Gynae
- Language (English) and computer skills
Education
MBBS (Bachelor of Medicine & Surgery)
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.
