Manager - Operational Transformation

Job Description To manage all Pre-Auth protocols, operation process, Bupa Pro project execution in terms of medical services provided and compliance of agreed contract within assigned providers handled by the providers management, insurance office, Bupa PA team are “as per defined medical, policy guidelines, agreed protocols and compatible with internal stakeholders agreement standards”, aiming to help reach customer experience excellence ( CXE ), with cost control, safe-guarding member’s health & safety, & also being compliant with SAMA, CHI Regulations & BUPA values. Service Management & Medical cost • Managing Bupa Pro projects with close mointoring of medical services provided in term of operation process flow and cusmtore jorney by managing the realtionship with the providers that are related to PA Protocols implemntaions to secure the bext CXE with no cost impact. • Ensure all cases handled by the team is based on common medical practice and aligned with BUPA protocols and policy. • Ensure the decisions taken by the team/ proceeded by insuarance office are according to the agreement’s terms & conditions in order to prevent abuse, fraud and overtreatment and as well ensure CXE. Quality medical decision & Patient safety • Ensure high customer satisfaction under Bupa pro scope in line with BUPA values and business strategy and protocols agrred with the providers. • Ensure compliance to SAMA and CHI regulations during medical adjudication.Ensure the medical decisions are consistent and are implemented based on clinical and practice guidelines signed off by the organization. • Ensure medical services case mangment is handled as per agreed process and mointor that. Efficiency management • Ensure and monitor that the adjudicating requests and case mangment for PA team is as per accepted medical practice and as per Bupa medical protocol thereby securing CX, and safety from medical abuse. • Ensure that all hospital field visites and documnted with targted outcomes. • Improve decision making skills on individual level and support to deliver the kneladge to the provider side. Operation excellence • Process improvement initiatives to achieve excellence. • Lead with the team for proper commuincaiton with hospitals and bupa stekholders to ensure service delivery. Capability Building & People Management • Ensure and facilitate goal setting; manage and constantly review service performance. • Provide regular feedback, coaching and development. • Motivate, empower and enable direct reports by providing the necessary tools and support. Support the business & communicate effectivily • Active partcipaing in reprting process of Bupa pro project. • Report any deviation of our agreement or critical cases with invloved parties. • Take active part in complaint management and communicate effectively (inter/intra department). • Manage any crises effectively based on already set business continuity plan. Compliance to policy and Regulation • Ensure applying terms and conditions of Bupa and CHI policy. • Highlight and report fraud, abuse in ccoperation with PA Ops and utilization team. Skills • 3 years in medical insurance/administrative field • 2 years in medical /clinical field practice • Clinical experience as General Practitioner / Emergency / Family Medicine • Medical insurance practice • Leadership and Analytical skills • Crisis Management

Manage all Pre-Auth protocols, operation process, Bupa Pro project execution in terms of medical services provided and compliance of agreed contract within assigned providers handled by the providers management, insurance office, Bupa PA team. Service Management & Medical cost: manage Bupa Pro projects with close monitoring of medical services provided in terms of operation process flow and customer journey by managing relationships with providers related to PA Protocols implementations to secure the best CXE with no cost impact; Ensure all cases handled by the team are based on common medical practice and aligned with BUPA protocols and policy; Ensure decisions taken by the team/insurance office are according to the agreement’s terms & conditions to prevent abuse, fraud and overtreatment and ensure CXE. Quality medical decision & Patient safety: ensure high customer satisfaction under Bupa pro scope in line with BUPA values and business strategy and protocols agreed with providers; ensure compliance to SAMA and CHI regulations during medical adjudication; ensure medical decisions are consistent and implemented based on clinical and practice guidelines signed off by the organization; ensure medical services case management is handled as per agreed process and monitor that. Efficiency management: monitor that adjudicating requests and case management for PA team are per accepted medical practice and per Bupa medical protocol thereby securing CX and safety from medical abuse; ensure all hospital field visits are documented with targeted outcomes; improve decision making skills at individual level and support to deliver knowledge to the provider side. Operation excellence: process improvement initiatives to achieve excellence; lead with the team for proper communication with hospitals and Bupa stakeholders to ensure service delivery. Capability Building & People Management: ensure and facilitate goal setting; manage and constantly review service performance; provide regular feedback, coaching and development; motivate, empower and enable direct reports by providing necessary tools and support. Support the business & communicate effectively: actively participating in reporting process of Bupa pro project; report any deviation of our agreement or critical cases with involved parties; take active part in complaint management and communicate effectively (inter/intra department); manage any crises effectively based on already set business continuity plan. Compliance to policy and Regulation: ensure applying terms and conditions of Bupa and CHI policy; highlight and report fraud, abuse in cooperation with PA Ops and utilization team.