Medical Excellence Pre Authorisation

To ensure consistent & high-quality pre-authorization decisions (particularly rejections, pending, and reworks) that are in line with BUPA values & with the least medical and legal liabilities for the organization, before being released to the providers, thereby enabling high customer safety & excellent customer experience

Patient Safety & Quality Medical Decision:

• Ensure the medical decisions are consistently implemented and in accordance with BUPA clinical & practice guidelines
• Actively contribute in improving the QDI scoring (Achieving the target of Zero A & minimal B QDI)
• Investigate QDI cases assigned to them by the pre-authorization medical manager for detailed reports
• Ensure the medical decision to be in line with the common medical and market practice
• Highlight users' gaps and inconvenience trends regarding the medical decision making

Fraud, Abuse & Compliance Safeguarding:

• Provide second check on fraud, declaration and anti-selection cases
• Secure the decision making is in line with contractual and legal terms & conditions
• Highlight and report abusive and over-utilizing trends to the Pre-auth, Business and medical managers
• Track and report groups', members 'and providers' trends of breaching policy /contractual terms & conditions
Highlight and report policy & contractual violation (if any) to the pre-authorization business manager & medical manager

Operational Excellence & Adjudication Efficiency:

• Achieve the response time targeted by the business
• Achieve the contribution target set by the business
• Ensuring delivering BUPA promise to the members
Ensuring the high-quality medical decision to be reflected on achieving the QDI target set by the business

Customer Satisfaction & Stakeholder Engagement:

• Ensure the medical decision is justified, and the ability to reverse the decisions whenever it is unjustified, effecting the member health and safety
• Reporting the critical or catastrophic decisions to the Pre-authorization Medical Manager

Business Support & Capability Building:

• Participate actively in the Continuous medical programs of the pre-authorization department to disseminate his medical knowledge and experience to the pre-authorization team members.
• Participate actively in the coaching and capability building programs and activities of the pre-authorization department
• 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

• Medical clinical practice
• Medical insurance practice
• Computer skills are must
• University Degree ( MBBS , MBBCH ) in medicine and surgery
• Post graduate Medical Master Degree or Medical Diploma.
• 3 years experience at least in medical field (Hospital practicing)
• Language (English) and computer skills
• At least 3 years of medical / clinical field practice
• At least 1 year of insurance / administrative practice