Manager Medical Pre Authorisation

About the Role

Bupa Arabia is seeking a Manager - Medical Pre Authorisation to join their team in Riyadh. This full-time position is responsible for ensuring clinically appropriate and evidence-based preauthorization decisions. The role focuses on effective utilization management, regulatory compliance, and engaging with providers to safeguard patient outcomes and optimize healthcare resource utilization.

Key Responsibilities

• Apply evidence-based medicine, clinical guidelines, and policy terms during preauthorization reviews.
• Ensure appropriate utilization of healthcare services and prevent unnecessary costs.
• Support cost-containment initiatives through effective medical adjudication and utilization management.
• Ensure clinically sound and consistent medical decisions, monitoring decision quality and adherence to medical protocols.
• Promote provider satisfaction through effective communication and partnership management.
• Manage and escalate high-value, complex, or critical cases as required.
• Participate in complaint resolution and support business continuity efforts.
• Maintain effective communication with internal and external stakeholders.
• Report operational risks and critical incidents in a timely manner.

Compliance and Risk Management

• Ensure adherence to Bupa policies, medical protocols, and regulatory requirements.
• Comply with CHI regulations and governance standards.
• Identify, escalate, and report suspected fraud, waste, abuse, and anti-selection activities.
• Support audit readiness and compliance monitoring activities.

Qualifications and Experience

Candidates for this role should possess 3 years of relevant experience. The position requires a professional who can ensure clinically appropriate decisions while managing medical costs and maintaining compliance.

Work Environment

This is a full-time position based in Riyadh, focusing on medical pre-authorization processes within the healthcare insurance sector.