Manager Clinical Excellence

About the Role

Bupa Arabia is seeking a Manager - Clinical Excellence to join our team in Al Khobar. This full-time position involves managing inpatient cases throughout the care journey, ensuring clinical appropriateness, high quality, patient-centered service, and cost efficiency. The role requires 0-1 years of experience.

Key Responsibilities

• Apply evidence-based clinical guidelines and protocols to inpatient cases.
• Conduct clinical case reviews for medical necessity and appropriateness.
• Manage complex and high-risk cases, escalating as required.
• Assess care pathways, quality of care, and outcomes across internal and external care channels.
• Conduct medical FIs and hospital profiling.

Patient-Centric Service and Utilization Management

• Apply patient- and member-centric principles in clinical care management processes.
• Balance clinical appropriateness, cost efficiency, and customer experience in care decisions.
• Conduct proactive engagement with high-risk and chronic patients to improve experience and outcomes.
• Coordinate with onsite and third-party providers on quality checks and documentation, addressing failures promptly.
• Review admission appropriateness and level of care.
• Monitor length of stay and support discharge planning.
• Identify high-cost cases and recommend interventions and cost-containment initiatives.

Onsite Adjudication and Quality Assurance

• Verify, audit, and report all inpatient services incurred.
• Review and process inpatient claims onsite against medical policy, line items, invoices, and adjudication guidelines.
• Apply medical judgment and agreement terms and conditions to prevent abuse, fraud, and overtreatment.
• Escalate high-profile and high-value claims for decision.
• Coordinate with hospitals to resolve inpatient claim issues.
• Apply quality standards across clinical care management.
• Conduct clinical quality assurance and quality control checks.
• Monitor adherence to clinical guidelines, protocols, and regulatory requirements.
• Track quality indicators in daily operations and recommend improvements that standardize clinical practice.
• Document clinical decisions to support audit and compliance.

Experience and Qualifications

• 0-1 years of relevant experience.

Application Process

Candidates interested in this role are encouraged to apply.