Manager - Medical Pre Authorisation

BUPA Arabia; Riyadh; On-site; SAR 180,000 - 300,000; Full time

Job summary

BUPA Arabia is seeking a professional to oversee Medical Cost & Service Management, Quality Medical Decision & Patient Safety, and stakeholder engagement. The role emphasizes evidence‑based preauthorization, regulatory compliance, and safeguarding patient outcomes while optimizing healthcare resource use.

Responsibilities include ensuring clinically sound decisions, monitoring decision quality, managing high‑value cases, resolving complaints, and reporting risks.

Responsibilities

• Apply evidence-based medicine, clinical guidelines, and policy terms during preauthorization review.
• Ensure appropriate utilization of healthcare services while preventing unnecessary costs.
• Support cost-containment initiatives through effective medical adjudication and utilization management.
• Ensure clinically sound and consistent medical decisions.
• Monitor decision quality and adherence to medical protocols.
• Promote provider satisfaction through effective communication and partnership management.
• Manage and escalate high-value, complex, or critical cases when required.
• Participate in complaint resolution and support business continuity efforts.
• Maintain effective communication with internal and external stakeholders.
• Report operational risks and critical incidents in a timely manner.
• Ensure adherence to Bupa policies, medical protocols, and regulatory requirements.
• Comply with CHI regulations and governance standards.
• Identify, elevate, and report suspected fraud, waste, abuse, and anti-selection activities.
• Support audit readiness and compliance monitoring activities.

Job description

Ensure clinically appropriate, evidence-based preauthorization decisions through effective utilization management, regulatory compliance, and provider engagement, while safeguarding patient outcomes, enhancing customer experience, and optimizing healthcare resource utilization.

Medical Cost & Service Management

• Apply evidence-based medicine, clinical guidelines, and policy terms during preauthorization review.
• Ensure appropriate utilization of healthcare services while preventing unnecessary costs.
• Support cost-containment initiatives through effective medical adjudication and utilization management.

Quality Medical Decision & Patient Safety

• Ensure clinically sound and consistent medical decisions.
• Monitor decision quality and adherence to medical protocols.
• Promote provider satisfaction through effective communication and partnership management.

Business Support & Stakeholder Management

• Manage and escalate high-value, complex, or critical cases when required.
• Participate in complaint resolution and support business continuity efforts.
• Maintain effective communication with internal and external stakeholders.
• Report operational risks and critical incidents in a timely manner.

Compliance, Governance & Risk Management

• Ensure adherence to Bupa policies, medical protocols, and regulatory requirements.
• Comply with CHI regulations and governance standards.
• Identify, elevate, and report suspected fraud, waste, abuse, and anti-selection activities.
• Support audit readiness and compliance monitoring activities.