Manager - Onsite Claims Management
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, day-in-day-out for smooth operation of business activity. 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 Managment and reflecting the right decision for every claim on the operations system. 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)
Job Location Jeddah , Saudi Arabia Job Role Medical, Healthcare, and Nursing Years of Experience Min: 4
