Manager - Onsite Claims Management
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Key skills for this role
About the Role
Bupa Arabia is hiring an Onsite Claims Manager to adjudicate inpatient medical claims at hospitals in Riyadh. The role requires reviewing claims for medical and commercial appropriateness, ensuring quality and fraud detection, and managing relationships with hospital management.
Key Skills for This Role
Responsibilities
- Review and process all IP cases/claims onsite the hospital in line with medical policy, line items, invoice and inpatient adjudication guidelines
- Ensure decisions are according to best medical standards and agreement terms to prevent abuse, fraud and overtreatment
- Assure each claim has been processed as per checklist steps involving checking physical claim and cross checking with electronic data
- Achieve daily target in terms number of claims
- Discuss high profile/high value claims with claims onsite manager where decision is difficult
- Manage IP claims issues with Hospital Management to assure collaborative partnership
- Achieve required quality through at least 95% accuracy level on daily quality audits
- Report abnormal trends of provider practice for adjudicated claims where needed
- Detect and escalate FWA cases to concerned teams
- Monitor identified providers' trends on a monthly basis
- Constantly upgrade knowledge and experience
- Offer professional help to team members and provide positive feedback
Requirements
- Clinical Experience
- Medical Insurance Experience
- MBBS (Bachelor of Medicine & Surgery)
Full Job Posting
Job Description
- To ensure that assigned provider’s Inpatient claims are medically & commercially adjudicated onsite the Hospital within the specified timeframe and within the targeted quality to achieve the business objective of ensuring that BUPA delivers high quality claim IP statements.
Adjudication
- Review and Process all the IP Cases/ claims onsite the hospital in line with medical policy, line items, invoice and Inpatient adjudication guidelines while using his/her medical background in conjunction with the instructed guidelines.
- Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse, fraud and overtreatment.
- Assures that each claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross checking with the electronic claims data on Edge, Hospital System, Hospital Management and reflecting the right decision for e
- Achieve daily target in terms number of claims.
- Discusses all high profile/high value claims with the claims onsite manager where the decision is difficult & well thought.
- Managing the IP Claims issues with the Hospital Management to assure collaborative partnership relationship.
Quality
- To achieve required quality through achieving at least 95% accuracy level on daily quality audits, in order to maintain the quality standard set for the job.
- Makes sound medical decisions that minimize the opportunity to be challenged by providers, and consults with the medical manager where in doubt.
Fraud and abuse identification
- Reports abnormal trends of provider practice for adjudicated claims where needed.
- Detects and escalates FWA cases to the concerned teams in line with Claims handling guidelines.
- Monitor the identified providers' trends, on a monthly basis.
Support & contribute to capability building
- Constantly upgrade his knowledge and experience in order to meet challenges.
- Offer professional help to the rest of his team members.
- Provide positive feedback and help in solving problems.
Workplace and Roving function
- The onsite doctor will adjudicate the claims onsite at the assigned hospitals on a daily base, based on the volume and flow of cases, roving between the assigned hospitals and being present at the hospital whenever needed.
Skills
- Clinical Experience.
- Medical Insurance Experience.
Education
- MBBS (Bachelor of Medicine & Surgery)
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