Medical Doctor (Pipeline) - Bupa Arabia

Job Description

Pre-Authorization
In this role you will support Bupa to ensure medical spend (In-Patient & Out-
Patient services) is controlled by ensuring that pre-authorization decisions
are within defined SAMA & CCHI regulations, accepted guidelines and high
quality medical standards, safeguarding the member's health & safety and
aligned to BUPA Values.
You will be responsible for the following:
* Adjudicate the cases (In-Patient & Out-Patient) based on common medical practice and in line with Bupa protocols and policy. Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse, fraud and overtreatment.
* Ensure working with high quality of decision making with Zero QDI (Quality Demerit Index) A or B. Ensure the medical decisions are consistent and are implemented based on clinical and practice guidelines signed off by the organization. Ensure high customer satisfaction in line with BUPA values and business strategy.
Clinical Excellence
In this role you are required to managing a group of hospitals to ensure that
inpatient customers are receiving optimal healthcare within agreed quality
parameters.
* To agree the case management plans with Consultants with Providers.
* Closely follow-up for all in-patient cases daily.
* To raise critical issues with Provider's Medical management as and when required.
* To ensure all approvals and rejections are agreed
* To ensure that all invoicing is as per the terms of the agreement.
Medical Claims Operation
* Process all the daily batches of claims assigned in line with medical policy and Inpatient adjudication guidelines while using his/her medical background in conjunction with the instructed guidelines, day-in-day-out for smooth operation of business activity
* Assures that each IP claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross checking with the electronic claims data on Edge, and reflecting the right decision for every claim on the operations system
* Achieve daily target in terms number of claims processed
* Discusses all high profile/high value claims with the claims medical manager where the decision is difficult & well thought.

Healthcare Services
To deliver the healthcare partnership operations functions and supporting
healthcare partner projects in order to drive the healthcare partner pillar of
Bupa Arabia.
* Liaise with medical and non-medical staff at providers to ensure quality healthcare service for our members.
* Conduct Outbound calls to our members for Chronic Diseases ,doing Coaching , Medication Refill & case management through case interpretation doing promotional calls.
* Receive Inbound calls from our members for Medical advices, Medical Coaching as per the updated medical guidelines , Lab results interpretation , Refill of Chronic medications regards Refill policy and general assistance .
Medical Provider Relations
To manage the commercial and contractual relationship with Bupa network
providers so as to ensure compliance to regulations and the delivery of
business benefits.
* Set the targets aligned with the overall forecast.
* Analyze, monitor the cost effectiveness of the unit and utilization of services of the providers to control and drop it year after year.
* Plan for reconciliation meetings, this will include scheduling meetings, coordination with medical manager, preparation of financial figures and negotiation tools
* Negotiate the reconciliation with the providers to achieve the set targets

Skills

• 
  

  Ability to conduct business in English language.

  
  


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  Ability to work under pressure.

  
  


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  Strong communication skills.

  
  


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  Clinical experience in general practitioner or Emergency or Family Medicine.

  
  

Education

MBBS (Bachelor of Medicine & Surgery) with some expertise of Insurance is
preferred.

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