Pre Authorisation Process (TPA)

Job Description

To ensure that all Pre-Auth decisions taken by the team is as per defined policy guidelines that are compatible with high medical standards that help in safe-guarding member’s health & safety & also being compliant with TPA, CHI Regulations and BUPA values.

Key Accountabilities:

Medical cost & Service Management

• Ensure all cases adjudicated by the team is based on common medical practice and aligned with BUPA protocols and policy .
• Ensure the decisions taken by the team are according to the best medical standards and agreement’s terms & conditions in order to prevent abuse, fraud and overutilization.

Quality medical decision & Patient safety

• Ensure working with High Quality of decision making with Zero QDI (Quality Demerit Index) A or B
• Ensure the medical decisions are consistent and are implemented based on clinical and practice guidelines signed off by the organization.
• Ensure high customer satisfaction in line with BUPA values and business strategy
• Ensure compliance to TPA and CHI regulations during medical adjudication.

Operation excellence

• Process improvement initiatives to achieve excellence
• Lead the team and deliver service strategy agenda

Efficiency management

• Ensure that the adjudicating requests for his team is as per accepted medical practice and as per Bupa medical protocol thereby securing patient safety from medical abuse.
• Ensure achieving the daily Targets in term of productivity and speed answer for adjudicated requests
• Ensure proper interpretation and usage of clinical skills
• Improve decision making skills on individual level

Capability Building & People Management

• Ensure and facilitate goal setting; manage and constantly review individual performance
• Provide regular feedback, coaching and development
• Motivate, empower and enable direct reports by providing the necessary tools and support

Support the business & communicate effectively

• Discuss & report the requested reports by the clients with involved parties
• Take active part in complaint management and communicate effectively (inter/intra department)
• Participate effectively in weekly / monthly meetings
• Manage any crises effectively based on already set business continuity plan

Compliance to policy and Regulation

• Ensure applying terms and conditions of Bupa declaration policy in SMEs products
• Report all high Value claims as per agreed process
• Highlight and report fraud, abuse, and anti-selection
• Following CHI policy terms and conditions

Skills

• Postgraduate in Medicine / Masters in Business Studies, preferable .
• 5 years experience at least in medical field ( Hospital practicing ) or at insurance field
• Language (English) and computer skills
• Crabapple of producing efficient reports and presentations
• Clinical experience as General Practitioner / Emergency / Family Medicine
• Medical insurance practice
• Leadership and Analytical skills
• Crisis Management
• 3 years in medical insurance/administrative field
• 2 years in medical /clinical field practice