Clinical Excellence Job Khobar area,Eastern Province Saudi Arabia,Healthcare

Medical Outcomes Management and Monitoring

Apply evidence-based clinical guidelines and protocols to inpatient cases.
Conduct clinical case reviews for medical necessity and appropriateness.
Manage complex and high-risk cases, escalating where required.
Assess care pathways, quality of care and outcomes across internal and external care channels.
Conduct medical FIs and hospital profiling.

Patient-Centric Service

Apply patient- and member-centric principles in clinical care management processes.
Balance clinical appropriateness, cost efficiency and customer experience in care decisions.
Conduct proactive engagement with high-risk and chronic patients to improve experience and outcomes.
Coordinate with onsite and third-party providers on quality checks and documentation, and address failures promptly.
Support third-party customer relationship management programmes.

Utilization & Cost Management

Review admission appropriateness and level of care.
Review inpatient utilisation promptly, within the agreed standards of the inpatient end-to-end management programme.
Monitor length of stay and support discharge planning.
Identify high-cost cases and recommend interventions and cost-containment initiatives.
Audit and report fraud, coding abuse and non-compliance with coding standards.

Onsite Adjudication

Verify, audit and report all inpatient services incurred.
Review and process inpatient claims onsite against medical policy, line items, invoices and adjudication guidelines, cross-checking physical and electronic claims data.
Apply medical judgement and agreement terms and conditions to prevent abuse, fraud and over treatment.
Escalate high-profile and high-value claims for decision.
Coordinate with hospitals to resolve inpatient claim issues.

Quality Management

Apply quality standards across clinical care management.
Conduct clinical quality assurance and quality control checks.
Monitor adherence to clinical guidelines, protocols and regulatory requirements.
Track quality indicators in daily operations and recommend improvements that standardise clinical practice.
Document clinical decisions to support audit and compliance.