Job Description
To ensure that all Pre-Auth decisions taken by the team is as per defined policy guidelines that are compatible with high medical standards that help in safe-guarding member's health & safety & also being compliant with TPA, CHI Regulations and BUPA values.
Key Accountabilities:
Medical cost & Service Management:
- Ensure all cases adjudicated by the team is based on common medical practice and aligned with BUPA protocols and policy .
- Ensure the decisions taken by the team are according to the best medical standards and agreement's terms & conditions in order to prevent abuse, fraud and overutilization.
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
- Ensure compliance to TPA and CHI regulations during medical adjudication.
Operation excellence:
- Process improvement initiatives to achieve excellence
- Lead the team and deliver service strategy agenda
Efficiency management:
- Ensure that the adjudicating requests for his team is as per accepted medical practice and as per Bupa medical protocol thereby securing patient safety from medical abuse.
- Ensure achieving the daily Targets in term of productivity and speed answer for adjudicated requests
- Ensure proper interpretation and usage of clinical skills
- Improve decision making skills on individual level
Capability Building & People Management:
- Ensure and facilitate goal setting; manage and constantly review individual performance
- Provide regular feedback, coaching and development
- Motivate, empower and enable direct reports by providing the necessary tools and support
Support the business & communicate effectively:
- Discuss & report the requested reports by the clients with involved parties
- Take active part in complaint management and communicate effectively (inter/intra department)
- Participate effectively in weekly / monthly meetings
- Manage any crises effectively based on already set business continuity plan
Compliance to policy and Regulation:
- Ensure applying terms and conditions of Bupa declaration policy in SMEs products
- Report all high Value claims as per agreed process
- Highlight and report fraud, abuse, and anti-selection
- Following CHI policy terms and conditions
Skills
- Postgraduate in Medicine / Masters in Business Studies, preferable .
- 5 years experience at least in medical field ( Hospital practicing ) or at insurance field
- Language (English) and computer skills
- Crabapple of producing efficient reports and presentations
- Clinical experience as General Practitioner / Emergency / Family Medicine
- Medical insurance practice
- Leadership and Analytical skills
- Crisis Management
- 3 years in medical insurance/administrative field
- 2 years in medical /clinical field practice
