Internal Medicine Pre Authorization

To ensure consistent & high quality Pre-Authorization decisions in Internal Medicine, Pediatric and Ob- Gynae specialties and related sub specialties , (particularly complaints related to regulator and big groups managements either related to rejections, pending and reworks) that are in line with BUPA values & with the latest most updated applied medical and legal liabilities for the organization ,either before being released to the providers or after the initial conveyed decision , thereby enabling high customer safety , excellent customer experience and regulatory compliance

Patient safety & customer experience

• Ensure patient safety & better customer experience by re-adjudicating all the rejections & pending cases before being sent to the providers to achieve Zero A & B QDI , for the cases concentrated to their specialities but not limited to.
• Ensure the medical decision is justified, and the ability to reverse the decisions whenever it is unjustified, effecting the member health and safety
• Secure the internal quality check and minimize the medical liabilities due to wrong or unjustified decisions related to their specialties and subspecialities
• Reporting the critical or catastrophic decisions to the Pre-authorization Medical Manager

Ensure high quality medical decision

• Ensure the medical decisions are consistantly implemented and in accordance with BUPA clinical & practice guidelines
• Actively contribute in improving the QDI scoring (Achieiving the target of Zero A & B QDI)
• Investigate QDI cases assigned to them by the pre-authorization medical manager for detailed reports
• Ensure the medical decision to be in line with the common medical and market practice
• Highlight users' gaps and inconvenience trends regarding the medical decision making

Secure the organization against Fraud & abuse

• Provide second check on fraud , declaration and anti-selection cases
• Secure the decision milking is in line with contractual and legal terms & conditions
• Highlight and report abusive and over-utilizing trends to the Pre-auth, Business and medical managers specially related to their specialties and sub specialties.
• Track and report groups', members 'and providers' trends of breaching policy /contractual terms & conditions
• Highlight and report policy & contractual violation (if any) to the pre-authorization business manager & medical manager

Achieve operational excellence and improving adjudication efficiency

• Achieve the response time targeted by the business
• Achieve the contribution target set by the business
• Ensuring delivering BUPA promise to the members
• Ensuring the high quality medical decision to be reflected on achieving the QDI target set by the business

Secure and achieve customer satisfaction

• Handle the VIP and hi-value client requests that are to be reported to him whenever a rejection or pending is most likely, and ensure achieving the response time targeted by the business
• Take active part in meetings with customers to solve any outstanding issues resulted from execution of the pre-authorization process

Support the business and secure it from commercial damage and/or legal liabilities

• Assess and submit detailed reports that are fact based and on correct medical and scientific back ground for all complaint cases, regulatory and/ or legal disputes related to their sepcialities and sub specialities
• Discuss the high value claims and/or critical cases with the providers’ consultants related to the specialties and subspecialities.
• Take active part in all activities related to smooth running of the daily work of the team including system upgrade, reporting and research
• May participate and /or serve on unit’s committees and task forces
• Maintain full cooperation with colleagues in Sales and Customer service departments by providing them with all the support needed to solve complaints arising as a result of preauthorization process

Support & contribute in capability building

• Participate actively in the Continuous medical programs of the pre-authorization department to disseminate his medical knowledge and experience to the pre-authorization team members sepcifiaclly related to their specailities and sub specialities but not limitied to .
• Participate actively in the coaching and capability building programs and activities of the pre-authorization department
• 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