✨ AI Summary
Bupa Arabia is seeking a Manager of Medical Excellence Pre-Authorization to oversee medical services, ensure provider compliance, and enhance customer experience without impacting costs. This role involves monitoring pre-authorization standards, providing guidance to insurance offices, and ensuring high-quality medical decisions. The manager will also focus on customer satisfaction metrics, provider communication, adherence to Bupa policies, and reporting any fraud or abuse. Efficiency management includes monitoring adjudicating requests and case management to meet daily targets and improve decision-making skills.
Operational excellence and capability building are crucial, with initiatives for process improvement and facilitating goal setting for customer excellence. The role demands providing regular feedback, coaching, and development, motivating collaboration, and effective communication with stakeholders. This includes discussing high-value claims, managing complaints, and reporting any crises. The ideal candidate will have clinical experience as a General Practitioner, Emergency, or Family Medicine physician, and experience in medical insurance practice.
Requirements
The role requires ensuring alignment with medical services regulations and contract terms with providers. Key responsibilities include monitoring pre-authorization standards for customer experience and provider compliance, managing medical costs, and ensuring high-quality medical decisions for patient safety. The candidate must also possess strong people management, communication, and process improvement skills.
Description
Job DescriptionTo 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 ManagementMonitoring of the processes agreed with the Provider are going in line with operational instructionsProviding guidance for the Insurance office and management inside providers to achieve best parameters for Customer experience improvement without cost impact. Quality medical decision & Patient safetyEnsure high-quality decisions regarding process handling and monitoringMonitor customer satisfaction perception metrics inside Providers ( CSAT & TNPS ) .Ensure a high level of communication with Providers, delivering best operational mutual agreementsEnsure applying terms and conditions of Bupa PolicyAdherence to CHI policy and regulationsHighlight and report fraud, abuse, and anti-selection Efficiency managementMonitor 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 productivityEnsure proper interpretation and usage of clinical skills and operational excellenceImprove decision-making skills on an individual level Operation excellenceProcess improvement initiatives to achieve excellenceFollow operational instructions and apply to relevant processes Capability Building & People ManagementEnsure and facilitate goal setting of Customer excellenceProvide regular feedback, coaching and developmentMotivate, encourage collaboration between internal and external stakeholders Support the business & communicate effectivelyDiscuss & report the high value claims and/or critical cases with involved partiesTake active part in complaint management and communicate effectively (inter/intra department)Report any crisis and adhere to instructions related to itSkillsLanguage (English) and basic computer skillsPreference:Clinical experience as General Practitioner / Emergency / Family MedicineMedical insurance practice