Pre Authorization

Job Description

Enhancing the CX of clients concerned with non-approved cases through applying the PA decision review, case management process, direct contact with clients, and coordination with both internal and external stakeholders within a defined time frame and restrictions of TOB. Moreover, pinpoint and tackle the root causes that result in the non-approval to enhance the volume and quality of the non-approval decisions.

Manage the MCU Recovery work list cases

• Review cases appearing on the MCU list, either diverted from the PA work list or created by other stakeholders, to ensure the quality of the decision as well as the application of TOB guidance by PA users / automated system.

• Applying the processes of case management for the work-list cases through interaction with providers, POC teams, customer care, and other stakeholders to guarantee the optimum management of cases in order to enhance CX within the boundaries of PA protocols, efficiencies, and TOB restrictions.

• Working in close contact with external stakeholders such as providers and treating doctors to ensure mutual understanding of both TOB restrictions and needed medical management requirements, and to increase the collaboration towards better CX.

• Good judgment, adaptive business intuition, and strong teamwork skills to work well with team members

Perform recovery calls when needed/requested

• Direct interaction with clients through phone calling for explanation of decision, process, and obtain necessary data or perform investigations when needed as part of the case management.

• Act as a medical reference backline support to front liners such as POC teams and customer care, CCHI, Social media, etc., by responding to requests to call the member and capture their complaints and concerns over medical decisions.

• Good communication skills and ample knowledge of medical practices as well as PA practices, and capable of working under pressure and high-standard service delivery requirements

• Capability to work within the frame of legal and operational requirements, which define the guidelines of interaction with clients, either imposed by Bupa, regulators, or the client institution.

Actively share in analysis and problem-solving

• Coordinate with data analysts, and use simple problem-solving and root cause analysis tools to monitor any deviation in the breakdown, volume, and origin of cases managed on the recovery list.

• Suggest and lead problem-solving to ensure efficient long-term management and root cause tackling of the MCU recovery list to continuously control the effect on CX and ensure the most efficient management of workload volumes.

Skills

• A degree in Medicine is preferable;Clinical Pharmacology can be accepted

• Any degree in Business, insurance or Quality Management is an advantage.

• Previous experience of Pre-authorization/POC/Claims is an advantage.

• Strong logical, analytic, Presentation, assessment, and interpretation skills

• Advanced communication and negotiation skills.

• Basic to intermediate knowledge of Microsoft Office

• Able to multitask and work well under stress

• Strong troubleshooting, problem-solving, and analytical skills, excellent follow-up skills

• Ability to effectively prioritize and execute tasks in a high-pressure environment