Job Description
To ensure alignment with all decisions and regulations in terms of medical services provided and agreed contract within assigned providers are handled by the provider management, insurance office, and all stakeholders. Monitoring of Preauthorization standards regarding Customer experience and ensuring provider compliance
- Medical cost & Service Management
Monitoring of the processes agreed with the Provider are going in line with operational instructions
Providing guidance for the Insurance office and management inside providers to achieve best parameters for Customer experience improvement without cost impact.
- Quality medical decision & Patient safety
Ensure high-quality decisions regarding process handling and monitoring
Monitor customer satisfaction perception metrics inside Providers ( CSAT & TNPS ) .
Ensure a high level of communication with Providers, delivering best operational mutual agreements
Ensure applying terms and conditions of Bupa Policy
Adherence to CHI policy and regulations
Highlight and report fraud, abuse, and anti-selection
Monitor that the adjudicating requests and case management for PA team is as per accepted medical practice and as per Bupa medical protocol, thereby securing CX, and safety from medical abuse.
Ensure achieving the daily Targets in terms of productivity
Ensure proper interpretation and usage of clinical skills and operational excellence
Improve decision-making skills on an individual level
Process improvement initiatives to achieve excellence
Follow operational instructions and apply to relevant processes
- Capability Building & People Management
Ensure and facilitate goal setting of Customer excellence
Provide regular feedback, coaching and development
Motivate, encourage collaboration between internal and external stakeholders
- Support the business & communicate effectively
Discuss & report the high value claims and/or critical cases with involved parties
Take active part in complaint management and communicate effectively (inter/intra department)
Report any crisis and adhere to instructions related to it
Skills
Language (English) and basic computer skills
Preference:
Clinical experience as General Practitioner / Emergency / Family Medicine
Medical insurance practice
