Main Responsibilities
To provide support for the clinical team colleagues to assess, plan, implement and regularly evaluate the customer`s holistic care in partnership with the multidisciplinary team, ensuring that the documentation is maintained and updated.
To undertake clinical audits policy and be involved in developing and leading service improvements.
Conduct data driven on-site audits of healthcare service providers, checking and evaluating accurately the medical record and related documents of the members to assess any discrepancy in the billing of services or in regard to the justification of the procedure(s)
Investigate suspected health insurance misuse and abuse cases related to Bupa members, collecting necessary documentation and as required, evidence to support his/her evaluation of the case
Ensure that business decisions and processes are documented in a professional manner with due confidentiality
Prepare the final audit report following the on-site audit and investigation; communicate with the providers regarding the audit findings and initiates the corrective adjustments, if any
Follow-up the recovery process related to the audited provider with Bupa`s Claims department until completion
Understand all policies and procedures relevant to the claims cycle and the auditing of providers, liaise regularly with all Bupa departments involved in the claims cycle as well as the contracting team to understand current provider issues and observed billing trends
Understand the local provider market and understands statistical analysis of provider behaviour prepared by Bupa`s Health Analytics department, commission specific data analysis as required by his/her audit plan
Acquainted with the legal requirements pertaining to auditing of providers
Offer technical support by continuous assessment and feedback concerning data quality and proper encoding of services
Work collaboratively with service partners in region and ensure the providers audit process is in place as per Bupa policy and procedures
Ensure that medical ethics and professionalism are maintained during the fulfilment of all tasks
The Ideal Candidate
Bachelors Degree in medicine or equivalent with demonstrable clinical experience and experience in the insurance industry insurance business especially Audit function.
Comply and meet BUPA standardized learning development and learning for clinicians.
Previous experience, preferably in international private medical insurance or in an administrative capacity within a hospital environment.
Strong Arabic and English, both written and verbal. Additional languages would be an advantage.
Strong numerical skills and the ability to understand and produce financial reconciliations
Knowledge of private hospital industry and its pricing and quality dynamics.
Track record of achieving targets with a consistent high level of quality.
Ability to be empathetic and view issues from the customers perspective while maintaining a professional outlook
Skilled in communication, able to liaise with doctors, hospitals, brokers, members, and colleagues
Good influencing skills with confidence and ability to challenge appropriately
Effective decision making and investigatory skills
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