وظيفة مدير التميز السريري شاغرة لدى بوبا العربية في الخبر

To manage inpatient cases onsite and across the care journey, ensuring care is clinically appropriate, of high quality, patient-centered and cost-efficient.

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.

·     Bachelor’s degree in medicine and surgery or equivalent

·       Master’s degree preferred

·       Excellent interpersonal and communication skills

·       Ability to explain complex medical information to patients and their families

·       Problem-Solving

·       Patient-Centred Care

·       Decision-Making

·       Knowledge of healthcare regulations and compliance

·       Healthcare and customer relationship experience

·       Hospital management experience is preferred