Clinical Excellence

Bupa Arabia for Cooperative Insurance Company; Al Khobar; On-site; SAR 150,000 - 210,000; Full time

Job summary

Bupa Arabia for Cooperative Insurance Company seeks a healthcare professional to lead Medical Outcomes Management and Monitoring, Patient-Centric Service, Utilization & Cost Management, Onsite Adjudication, and Quality Management across inpatient care. You will apply evidence-based guidelines, review cases for medical necessity, and coordinate with hospitals.

The role focuses on maintaining clinical integrity, cost efficiency, audit readiness, discharge planning and documenting decisions to

Responsibilities

• Apply evidence-based clinical guidelines and protocols to inpatient cases.
• Conduct clinical case reviews for medical necessity and appropriateness.
• Manage complex and high-risk cases, escalating where required.
• Assess care pathways, quality of care and outcomes across internal and external care channels.
• Conduct medical FIs and hospital profiling.
• Apply patient- and member-centric principles in clinical care management processes.
• Balance clinical appropriateness, cost efficiency and customer experience in care decisions.
• Conduct proactive engagement with high-risk and chronic patients to improve experience and outcomes.
• Coordinate with onsite and third-party providers on quality checks and documentation, and address failures promptly.
• Support third-party customer relationship management programmes.
• Review admission appropriateness and level of care.
• Review inpatient utilisation promptly, within the agreed standards of the inpatient end-to-end management programme.
• Monitor length of stay and support discharge planning.
• Identify high-cost cases and recommend interventions and cost-containment initiatives.
• Audit and report fraud, coding abuse and non-compliance with coding standards.
• Verify, audit and report all inpatient services incurred.
• Review and process inpatient claims onsite against medical policy, line items, invoices and adjudication guidelines, cross-checking physical and electronic claims data.
• Apply medical judgement and agreement terms and conditions to prevent abuse, fraud and overtreatment.
• Escalate high-profile and high-value claims for decision.
• Coordinate with hospitals to resolve inpatient claim issues.
• Apply quality standards across clinical care management.
• Conduct clinical quality assurance and quality control checks.
• Monitor adherence to clinical guidelines, protocols and regulatory requirements.
• Track quality indicators in daily operations and recommend improvements that standardise clinical practice.
• Document clinical decisions to support audit and compliance.

Job description

Medical Outcomes Management and Monitoring

• Apply evidence-based clinical guidelines and protocols to inpatient cases.
• Conduct clinical case reviews for medical necessity and appropriateness.
• Manage complex and high-risk cases, escalating where required.
• Assess care pathways, quality of care and outcomes across internal and external care channels.
• Conduct medical FIs and hospital profiling.

Patient-Centric Service

• Apply patient- and member-centric principles in clinical care management processes.
• Balance clinical appropriateness, cost efficiency and customer experience in care decisions.
• Conduct proactive engagement with high-risk and chronic patients to improve experience and outcomes.
• Coordinate with onsite and third-party providers on quality checks and documentation, and address failures promptly.
• Support third-party customer relationship management programmes.

Utilization & Cost Management

• Review admission appropriateness and level of care.
• Review inpatient utilisation promptly, within the agreed standards of the inpatient end-to-end management programme.
• Monitor length of stay and support discharge planning.
• Identify high-cost cases and recommend interventions and cost-containment initiatives.
• Audit and report fraud, coding abuse and non-compliance with coding standards.

Onsite Adjudication

• Verify, audit and report all inpatient services incurred.
• Review and process inpatient claims onsite against medical policy, line items, invoices and adjudication guidelines, cross-checking physical and electronic claims data.
• Apply medical judgement and agreement terms and conditions to prevent abuse, fraud and overtreatment.
• Escalate high-profile and high-value claims for decision.
• Coordinate with hospitals to resolve inpatient claim issues.

Quality Management

• Apply quality standards across clinical care management.
• Conduct clinical quality assurance and quality control checks.
• Monitor adherence to clinical guidelines, protocols and regulatory requirements.
• Track quality indicators in daily operations and recommend improvements that standardise clinical practice.
• Document clinical decisions to support audit and compliance.