Manager - Medical Excellence Pre Authorization (Mega AC)

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

• Efficiency management
  
  

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

• Operation excellence
  
  

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