Pre Authorization (Pipeline)

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 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 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 Surge