Executive Manager- Pre Authorisation Process (TPA)

Bupa Arabia; As Sudiyah; On-site; OMR 15,380 - 23,070; Full time

Job summary

Bupa Arabia is seeking a professional for a role focused on ensuring Pre-Auth decisions comply with medical standards while safeguarding member health. This position involves leading a team and maintaining high customer satisfaction aligned with BUPA values.

The candidate should have a postgraduate degree, at least 5 years of relevant experience, and strong leadership skills. The role offers an opportunity to impact healthcare service quality in Al Buraymi Governorate, Oman.

Qualifications

• Minimum 5 years experience in the medical or insurance field.
• Postgraduate degree preferred.
• Leadership and analytical skills required.

Responsibilities

• Ensure all adjudicated cases follow medical practices and BUPA protocols.
• Achieve customer satisfaction aligned with BUPA values.
• Lead team in service strategy and performance management.

Skills

Postgraduate in Medicine / Master’s in Business Studies

5+ years experience in the medical field or insurance field

English and computer skills

Clinical experience as General Practitioner / Emergency / Family Medicine

Medical insurance practice

Leadership and analytical skills

Crisis management

3 years in medical insurance/administrative field

2 years in medical/clinical field practice

Job description

Job Description

To ensure that all Pre‑Auth decisions taken by the team are as per defined policy guidelines that are compatible with high medical standards that help in safeguarding member’s health & safety & also being compliant with TPA, CHI Regulations and BUPA values.

Key Accountabilities

Medical cost & Service Management

• Ensure all cases adjudicated by the team are based on common medical practice and aligned with BUPA protocols and policy.
• Ensure the decisions taken by the team are according to the best medical standards and agreement’s terms & conditions in order to prevent abuse, fraud and overutilization.

Quality medical decision & Patient safety

• Ensure working with high quality of decision making with Zero QDI (Quality Demerit Index) A or B.
• Ensure the medical decisions are consistent and are implemented based on clinical and practice guidelines signed off by the organization.
• Ensure high customer satisfaction in line with BUPA values and business strategy.
• Ensure compliance to TPA and CHI regulations during medical adjudication.

Operation excellence

• Process improvement initiatives to achieve excellence.
• Lead the team and deliver service strategy agenda.

Efficiency management

• Ensure that the adjudicating requests for the team are as per accepted medical practice and as per BUPA medical protocol, thereby securing patient safety from medical abuse.
• Ensure achieving the daily targets in terms of productivity and speed answer for adjudicated requests.
• Ensure proper interpretation and usage of clinical skills.
• Improve decision making skills on an individual level.

Capability Building & People Management

• Ensure and facilitate goal setting; manage and constantly review individual performance.
• Provide regular feedback, coaching and development.
• Motivate, empower and enable direct reports by providing the necessary tools and support.

Support the business & communicate effectively

• Discuss & report the requested reports by the clients with involved parties.
• Take active part in complaint management and communicate effectively (inter/intra department).
• Participate effectively in weekly / monthly meetings.
• Manage any crises effectively based on already set business continuity plan.

Compliance to policy and Regulation

• Ensure applying terms and conditions of Bupa declaration policy in SME products.
• Report all high value claims as per agreed process.
• Highlight and report fraud, abuse, and anti‑selection.
• Follow CHI policy terms and conditions.

Skills

• Postgraduate in Medicine / Master’s in Business Studies, preferable.
• At least 5 years experience in the medical field (hospital practice) or insurance field.
• Language (English) and computer skills.
• Clinical experience as General Practitioner / Emergency / Family Medicine.
• Medical insurance practice.
• Leadership and analytical skills.
• Crisis management.
• 3 years in medical insurance/administrative field.
• 2 years in medical/clinical field practice.