In this role you will support Bupa to ensure medical spend (In-Patient & Out-Patient services) is controlled by ensuring that pre-authorisation decisions are within defined SAMA & CCHI regulations, accepted guidelines and high quality medical standards, safeguarding the member’s health & safety and aligned to BUPA Values.
You will be responsible for the following:
– Medial cost & Service Management: Adjudicate the cases (In-Patient & Out-Patient) based on common medical practice and in line with Bupa protocols and policy. Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse, fraud and overtreatment.
– High 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.
– Efficiency management: Ensure achieving the daily targets in terms of productivity & speed of response.
– Ensure proper interpretation and usage of clinical skills.
– Compliance to policy and Regulation: Report all high value claims as per agreed process.
– Highlight and report fraud, abuse, and anti-selection.
– Bachelor’s degree or post graduate degree in medical majors,
– Minimum 2 years’ experience.
– Ability to conduct business in English language.
– Ability to work under pressure.
– Strong communication skills.
– Clinical experience in general practitioner or Emergency or Family Medicine.