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 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.
Education
Medicine and Surgery
