Manager - Pre Authorization (Pipeline)

Job DescriptionTo 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 ManagementAdjudicate the cases (In-Patient & Out-Patient) based on common medical practice and in line 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 safetyEnsure working with high quality of decision making with Zero QDI (Quality Demerit Index) A or BEnsure 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 managementEnsure achieving the daily targets in terms of productivity & speed of response.Ensure proper interpretation and usage of clinical skills.Compliance to policy and RegulationReport 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 buildingConstantly 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.SkillsValid Saudi CommissionClinical experience in General practitioner / Emergency / Family MedicineInsurance experience preferableMinimum 3 years of clinical experience excluding internship year.EducationMedicine and Surge#J-18808-Ljbffr