Manager - Pre Authorization (Pipeline)

Bupa

  • Jeddah, Makkah
  • Training
  • Full-time
  • 25 days ago
Job DescriptionTo 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 ValuesMedial Cost & Service Management
  • Adjudicate the cases (In-Patient & Out-Patient) based on common medical prcatice 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.
EducationMedicine and Surgery

Bupa