Job Description
To adjudicate inpatient and outpatient pre-authorization requests accurately and within approved clinical, regulatory, and policy standards, controllingmedical expenditure while safeguarding member health and safety in line with Bupa values.
Medical Cost & Service Management:
- Adjudicate inpatient and outpatient pre-authorization cases in line with common medical practice, Bupa protocols, and policy.
- Apply the client agreement terms and conditions when reviewing each case.
Quality Medical Decisions & Patient Safety:
- Make consistent, clinically sound decisions based on approved clinical and practice guidelines.
- Safeguard member health and safety throughout the pre-authorization process.
Service Efficiency:
- Adjudicate cases promptly to maintain a responsive service to hospitals and members.
- Manage case volumes to sustain productivity and turnaround.
Compliance with Policy & Regulation:
- Process authorizations in line with company policy and applicable regulations.
- Escalate high-value transactions and claims through the agreed process.
Fraud, Abuse & Anti-Selection Reporting:
Identify and report suspected fraud, abuse, and anti-selection through the agreed channels.
Continuous Improvement:
Contribute to medical and operational projects that improve the pre-authorization function.
Skills
- Bachelor's degree in MBBS.
- Clinical experience in General Practice, Emergency, or Family Medicine.
- Ability to conduct business in the English language.
- Ability to work under pressure.
- Strong communication skills.
- 3 – 5 years.
