Manager - Clinical Excellence

المصدر: careers.bupa.com.sa · قد تتغير إتاحة الوظيفة على موقع الشركة.

تفاصيل الوظيفة

Job Description To manage inpatient cases onsite and across the care journey, ensuring care is clinically appropriate, of high quality, patient-centered and cost-efficient. Medical Outcomes Management and Monitoring ·        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. Patient-Centric Service ·        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. Utilization & Cost Management ·        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. Onsite Adjudication ·        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 overtreatment. ·        Escalate high-profile and high-value claims for decision. ·        Coordinate with hospitals to resolve inpatient claim issues. Quality Management ·        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. Skills ·       Bachelor’s degree in medicine and surgery or equivalent ·        Master’s degree preferred ·        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 Job Location Khobar, Saudi Arabia Job Role Doctors Preferred Candidate Career Level / Band Entry Level Years of Experience Min: 1 Minimum Degree Bachelor's degree Bupa Arabia Insurance Jeddah , Saudi Arabia 500 employees or more +966.9.200.00456 https://www.bupa.com.sa Bupa Arabia is a healthcare insurance company based in the Kingdom of Saudi Arabia. We are an associate business of Bupa Group, which is a global healthcare company with an international reach that extends across multiple business operations, practices, and resources. Founded in October 1997, Bupa Arabia was initially established through a partnership between Bupa Global International and Nazer Group, with the key focus to provide health insurance services with high quality and competitive prices, while ensuring a distinctive experience for customers. Bupa Arabia has since evolved into a fully Saudi-owned and operated company. Our transformation from a joint venture into a publicly traded company on the Saudi Stock Exchange occurred in 2008, as we made 40% of our shares available to the public during our Initial Public Offering (IPO). As a subsidiary of the global Bupa Group, we draw upon international expertise while maintaining a profound understanding of local healthcare requirements and regulations. This allows us to offer comprehensive healthcare insurance solutions tailored to the unique needs of the Saudi Arabian market. Bupa Arabia prides itself on its commitment to the wellbeing and development of its employees, providing them with the same standard of care, support, and professionalism that it expects to be delivered to its customers. Our core values shape every aspect of our work and culture: Commit – Own it with accountability and urgency. Collaborate – Win together through cross-functional synergy. Care – Put people first, both employees and customers. Similar Jobs See All This website uses cookies to ensure you get the best experience on our website.