Manager – Clinical Excellence Bupa Healthcare

Job Title: Manager – Clinical Excellence

To manage inpatient cases onsite and across the care journey, ensuring care is clinically appropriate, of high quality, patient-centered and cost-efficient.

Key Responsibilities:

• 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.
• 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.
• 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.
• 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.
• 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.

Experience

Required:

• Min: 1

Education

Qualifications:

• Bachelor’s degree in medicine and surgery or equivalent

Skills Required:

• Excellent interpersonal and communication skills
• Ability to explain complex medical information to patients and their families
• Problem-Solving
• Patient-Centred Care
• Decision-Making
• Knowledge of healthcare regulations and compliance
• Healthcare and customer relationship experience
• Hospital management experience is preferred

Employment / Job Type: Full Time

About the Company:

Bupa is an international healthcare organisation offering health insurance and medical services to customers around the world. Its operations span hospitals, clinics, dental centres and aged care, alongside workplace health and digital consultation services. Having no shareholders, Bupa reinvests its profits back into patient care and the wider business.

Company Industry: Healthcare

Department /

Functional Area:

Clinical Excellence

Closing Date: Not mentioned (apply as soon as possible)