Ensure medical cost control through managing benefit spend for Out Patient services only, making sure that decisions are within defined SAMA & CCHI regulations, accepted guidelines and high quality common medical standards safe guarding the member's health & safety and in line with Bupa Values.
The role responsible for the following:
- Medial cost & Service Management:
- Ensure the decisions are according to the best medical standards and agreements' terms & conditions in order to prevent abuse, fraud and overtreatment
- Ensure member safety through working with High Quality of decision making with Zero QDI (Quality Demerit Index) A or B
- Ensure the medical decisions are consistent and proper implementation of the clinical and practice guidelines signed off by the organization
- Ensure achieving of daily targets in terms of productivity & speed of response
- Ensure proper interpretation and usage of clinical skills
- Ensure compliance to policy and Regulation • Report all high Value claims as per agreed process with in Out Patient services
- Highlight and report fraud, abuse, and anti-selection Apply terms and conditions of Bupa declaration policy in SMEs products Following CCHI policy terms and conditions
- Support & contribute in capability building, constantly upgrade his knowledge and experience in order to meet challenges
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