Manager Medical Excellence Pre Authorization (Mega AC)📣 Job Ad

About the Role

Bupa Arabia is seeking a Manager Medical Excellence Pre Authorization (Mega AC) to join their team in Al Khobar, Eastern region. This full-time role is central to ensuring that all medical services provided and contract agreements within assigned providers align with established decisions and regulations.

Role Purpose and Context

The primary purpose of this position is to oversee and monitor pre-authorization standards, focusing on enhancing customer experience and ensuring comprehensive provider compliance. The role involves close collaboration with provider management, insurance offices, and various stakeholders to maintain operational integrity and service quality.

Key Responsibilities

• Monitor processes agreed with providers to ensure alignment with operational instructions.
• Provide guidance to insurance offices and provider management to achieve optimal customer experience parameters without adverse cost impact.
• Monitor the adjudication of requests and case management for the Pre-Authorization team, ensuring adherence to accepted medical practices and Bupa medical protocols.
• Ensure daily productivity targets are met.
• Promote proper interpretation and usage of clinical skills and operational excellence.
• Drive process improvement initiatives to achieve operational excellence.
• Follow and apply operational instructions to relevant processes.

Medical Quality and Compliance

• Ensure high-quality decisions regarding process handling and monitoring.
• Monitor customer satisfaction perception metrics within providers (CSAT & TNPS).
• Maintain a high level of communication with providers, fostering effective operational mutual agreements.
• Ensure the application of Bupa Policy terms and conditions.
• Adhere to CHI policy and regulations.
• Identify and report instances of fraud, abuse, and anti-selection.

Leadership and Stakeholder Engagement

• Facilitate and ensure goal setting for customer excellence.
• Provide regular feedback, coaching, and development to team members.
• Motivate and encourage collaboration among internal and external stakeholders.
• Discuss and report high-value claims and critical cases with involved parties.
• Actively participate in complaint management and communicate effectively across departments.
• Report any crises and adhere to related instructions.

Qualifications and Experience

Candidates should possess 5 to 10 years of relevant experience in a similar capacity.