Medical Pre Authorisation (Mega AC)
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Key skills for this role
About the Role
Bupa is seeking a Medical Pre-Authorisation Manager to adjudicate inpatient and outpatient pre-authorization requests accurately, controlling medical expenditure while safeguarding member health.
Key Skills for This Role
Responsibilities
- Adjudicate inpatient and outpatient pre authorization cases in line with common medical practice, Bupa protocols, and policy
- Apply the client agreement terms and conditions when reviewing each case
- Make consistent, clinically sound decisions based on approved clinical and practice guidelines
- Safeguard member health and safety throughout the pre authorization process
- Adjudicate cases promptly to maintain a responsive service to hospitals and members
- Manage case volumes to sustain productivity and turnaround
- Process authorizations in line with company policy and applicable regulations
- Escalate high value transactions and claims through the agreed process
- Identify and report suspected fraud, abuse, and anti selection through the agreed channels
- Contribute to medical and operational projects that improve the pre authorization function
Requirements
- Bachelor's degree in MBBS
- Clinical experience in General Practice, Emergency, or Family Medicine
- Ability to conduct business in the English language
- Ability to work under pressure
- Strong communication skills
- 3 – 5 years of experience
Full Job Posting
Job Description
- To adjudicate inpatient and outpatient pre authorization requests accurately and within approved clinical, regulatory, and policy standards, controlling medical expenditure while safeguarding member health and safety in line with Bupa values.
Medical Cost & Service Management
- Adjudicate inpatient and outpatient pre authorization cases in line with common medical practice, Bupa protocols, and policy.
- Apply the client agreement terms and conditions when reviewing each case.
Quality Medical Decisions & Patient Safety
- Make consistent, clinically sound decisions based on approved clinical and practice guidelines.
- Safeguard member health and safety throughout the pre authorization process.
Service Efficiency
- Adjudicate cases promptly to maintain a responsive service to hospitals and members.
- Manage case volumes to sustain productivity and turnaround.
Compliance with Policy & Regulation
- Process authorizations in line with company policy and applicable regulations.
- Escalate high value transactions and claims through the agreed process.
Fraud, Abuse & Anti Selection Reporting
- Identify and report suspected fraud, abuse, and anti selection through the agreed channels.
Continuous Improvement
- Contribute to medical and operational projects that improve the pre authorization function.
Skills
- Bachelor's degree in MBBS.
- Clinical experience in General Practice, Emergency, or Family Medicine.
- Ability to conduct business in the English language.
- Ability to work under pressure.
- Strong communication skills.
- 3 – 5 years.
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