Job DescriptionEnsure 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.
SkillsMinimum 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
