Healthcare Services (MCU) (TPA) - Pipeline

Job Description

To work within Medical care unit which has 3 subunits : Rejection recovery ( to make calls engagements with unapproved cases and to respond to the frontliners queries) , Referral unit ( to facilitate clients referrals and services availability , to work on Referral cards platform for members per diem expenses) , checkup unit ( to work with clients and the providers to perform the requested checkups ( occupational and general) and the pre employment candidates and to validate the results before delivering them to the clients. Healthcare services adjuvant to the preauthorization either by reviewing the non-approved casesor Referral cases, services management and occupational checkup services management through applying of PA decision review and or client SLA’s, case management process, direct contact with clients, and coordination with both internal and external stakeholders within a defined time frame and restrictions of TOB. More-over, pinpoint and tackle the root causes that result in the non-approval to enhance the volume and quality of the non-approval decisions.

Client interactions

• To make sure that all requests being resonded to within the agreed KPI.

• To validate the requested checkups and preferred location.

• Good communication with aramco and Key accounts delegates team.

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

• Review referral cases to proceed with allocting the requested services and issuning the needed referral document when requested.

• Review referral cards requests and proceeding according to the client guidelines

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

Communications with internal and external stakeholders

• Direct interaction with clients through phone calling for explanation of decision, process and obtain necessary data for proper adjudication.

• Respond to the internal stakeholders queries via CMTEmails.

• To perform oubound calls for members experince assessment.

• To ensure timley response from the providers regarding the appointments and the attendance and results submission.

• To validate the submitted results from the providers before handing it to the client.

• To work on checkup platform on timely and quality wise matter.

• To ensure all transactions and repots requested is performed.

• To communicate with the providers for the congentgencies and contious education about the packages and the special requests.

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

Data 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.

• Actively participate in process enhancements, KAIZENS and innovations

• Recording of the done transactions in platformsexcel sheets on daily basis if needed.

Skills

• logical, analytic, Presentation, assessment and interpretation skills

• communication and negotiation skills.

· Basic to intermediate knowledge of Microsoft Office

· Able to multitask and work well under stress.

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

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

· A degree in Medicine (MBBS)

· Any degree in Business, insurance or quality management is an advantage.

· Any degree/ training in Excel, Data Management and Dashboards, Business Writing,

·Client Management shall be considered