مدير الموافقات الطبية المسبقة

Job Description

Ensure clinically appropriate, evidence-based preauthorization decisions through effective utilization management, regulatory compliance, and provider engagement, while safeguarding patient outcomes, enhancing customer experience, and optimizing healthcare resource utilization.

Medical Cost & Service Management

• Apply evidence-based medicine, clinical guidelines, and policy terms during preauthorization review.

• Ensure appropriate utilization of healthcare services while preventing unnecessary costs.

• Support cost-containment initiatives through effective medical adjudication and utilization management.

Quality Medical Decision & Patient Safety

· Ensure clinically sound and consistent medical decisions.

• Monitor decision quality and adherence to medical protocols.

• Promote provider satisfaction through effective communication and partnership management.

Business Support & Stakeholder Management

• Manage and escalate high-value, complex, or critical cases when required.
• Participate in complaint resolution and support business continuity efforts.
• Maintain effective communication with internal and external stakeholders.
• Report operational risks and critical incidents in a timely manner.

Compliance, Governance & Risk Management

• Ensure adherence to Bupa policies, medical protocols, and regulatory requirements.
• Comply with CHI regulations and governance standards.
• Identify, escalate, and report suspected fraud, waste, abuse, and anti-selection activities.
• Support audit readiness and compliance monitoring activities.

Skills

Minimum 3 years of Experience – Medical

Clinical experience as General Practitioner / Emergancy / Family Medicine

Medical insurance practice

Language (English) and basic computer skills

Bachelor’s in medicine or equivalent

Postgraduate in Medicine