Manager - Pre Authorization (Pipeline)
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Key skills for this role
About the Role
Bupa Arabia seeks a Pre-Authorization Manager to control medical spend by ensuring pre-authorization decisions comply with SAMA & CCHI regulations and high medical standards.
Key Skills for This Role
Responsibilities
- Adjudicate in patient and out patient cases based on medical practice and Bupa protocols
- Ensure decisions align with best medical standards and agreement terms to prevent abuse, fraud, and overtreatment
- Achieve zero Quality Demerit Index (QDI) A or B
- Ensure consistent medical decisions based on clinical and practice guidelines
- Achieve daily targets in productivity and speed of response
- Report high value claims as per agreed process
- Highlight and report fraud, abuse, and anti selection
- Apply terms and conditions of Bupa declaration policy in SME products
- Follow CCHI policy terms and conditions
- Constantly upgrade knowledge and experience
- Offer professional help to team members and provide positive feedback
Requirements
- Valid Saudi Commission
- Clinical experience in General Practitioner / Emergency / Family Medicine
- Minimum 3 years of clinical experience excluding internship year
- Insurance experience preferable
- Degree in Medicine and Surgery
Full Job Posting
Job Description
- To ensure medical spend (In Patient & Out Patient services) is controlled by ensuring that pre authorization 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
Medial Cost & Service Management
- Adjudicate the cases (In Patient & Out Patient) based on common medical practice and inline 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
- Apply terms and conditions of BUPA declaration policy in SME products
- Follow CCHI policy’s terms and conditions
Support & contribute in capability building
- 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
- Valid Saudi Commission
- Clinical experience in General practitioner / Emergency / Family Medicine
- Insurance experience preferable
- Minimum 3 years of clinical experience excluding internship year
Education
- Medicine and Surgery
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