To ensure medical spend (In-Patient & Out-Patient services) is controlled by ensuring that pre-authorization decisions are within defined SAMA & CCHI regulations, accepted guidelines and high quality medical standards, safeguarding the member's health & safety and aligned to BUPA Values.
Medial Cost & Service Management
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Adjudicate the cases (In-Patient & Out-Patient) based on common medical practice and inline with Bupa protocols and policy .
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Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse, fraud and overtreatment
High quality medical decision & patient safety
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Ensure working with high quality of decision making with Zero QDI (Quality Demerit Index) A or B
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Ensure the medical decisions are consistent and are implemented based on clinical and practice guidelines signed off by the organization.
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Ensure high customer satisfaction in line with BUPA values and business strategy
Efficiency management
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Ensure