Manager - Medical Excellence Pre Authorization (Mega AC)

Job Description

To ensure alignment with all decisions and regulations in terms of medical services provided and agreed contract within assigned providers are handled by the provider management, insurance office, and all stakeholders. Monitoring of Preauthorization standards regarding Customer experience and ensuring provider compliance.

Monitoring of the processes agreed with the Provider are going in line with operational instructions.

Providing guidance for the Insurance office and management inside providers to achieve best parameters for Customer experience improvement without cost impact.

Ensure high-quality decisions regarding process handling and monitoring.

Monitor customer satisfaction perception metrics inside Providers ( CSAT & TNPS ).

Ensure a high level of communication with Providers, delivering best operational mutual agreements.

Ensure applying terms and conditions of Bupa Policy.

Adherence to CHI policy and regulations.

Highlight and report fraud, abuse, and anti-selection.

Monitor that the adjudicating requests and case management for PA team is as per accepted medical practice and as per Bupa medical protocol, thereby securing CX, and safety from medical abuse.

Ensure achieving the daily Targets in terms of productivity.

Ensure proper interpretation and usage of clinical skills and operational excellence.

Improve decision-making skills on an individual level.

Process improvement initiatives to achieve excellence.

Follow operational instructions and apply to relevant processes.

Ensure and facilitate goal setting of Customer excellence.

Provide regular feedback, coaching and development.

Motivate, encourage collaboration between internal and external stakeholders.

Discuss & report the high value claims and/or critical cases with involved parties.

Take active part in complaint management and communicate effectively (inter/intra department).

Report any crisis and adhere to instructions related to it.

Language (English) and basic computer skills

Clinical experience as General Practitioner / Emergency / Family Medicine

Medical insurance practice