Manager Claims Management📣 إعلان

Role Overview

Bupa Arabia is seeking a Manager Claims Management to join their team in Riyadh, Saudi Arabia. This full-time position is central to ensuring the accurate and timely medical and commercial adjudication of Inpatient claims directly at assigned hospital sites. The role focuses on delivering high-quality Inpatient (IP) claim statements, aligning with Bupa's business objectives. Candidates should possess 0-1 years of relevant experience.

Core Responsibilities: Claims Adjudication

• Review and process all Inpatient (IP) cases and claims onsite at hospitals, ensuring adherence to medical policy, line items, invoices, and established adjudication guidelines.
• Apply medical background in conjunction with instructed guidelines to ensure smooth business operations and decisions that comply with best medical standards and agreement terms.
• Process each claim according to a defined checklist, including cross-checking physical or scanned claims with electronic data on Edge, Hospital System, and Hospital Management.
• Achieve daily targets for the number of claims processed.
• Discuss high-profile or high-value claims with the claims onsite manager when decisions require careful consideration.
• Manage IP claims issues directly with Hospital Management to foster collaborative partnerships.

Quality Assurance and Fraud Prevention

• Maintain a minimum of 95% accuracy on daily quality audits, in line with the quality standards set for the position.
• Make sound medical decisions to minimize the opportunity for challenges by providers, consulting with the medical manager when in doubt.
• Report abnormal trends in provider practice for adjudicated claims as needed.
• Detect and escalate cases of Fraud, Waste, and Abuse (FWA) to the concerned teams, adhering to claims handling guidelines.
• Monitor identified provider trends on a monthly basis.

Professional Development and Team Support

• Continuously upgrade knowledge and experience to meet evolving challenges in claims management.
• Offer professional assistance to other team members and provide positive feedback to aid in problem-solving.

Work Setting

This role operates as an onsite function, requiring the individual to adjudicate claims daily at assigned hospitals based on the volume and flow of cases. The position involves roving between assigned hospitals and maintaining presence at hospital sites whenever required.

About Bupa Arabia

Bupa Arabia is a prominent healthcare provider dedicated to delivering high-quality services. This role offers an opportunity to contribute to the efficient and ethical management of healthcare claims within a dynamic and professional environment.