Duties and Responsibilities:

• Lead the approval and care management department, be a final medical and operational reference within approval in line with the organization values, and within defined policy guidelines.
• Improve the customer experience, and cost effective with securing the organization from abuse, fraud, medical and legal liabilities, with ensuring the proper implementation and execution of the medical and insurance protocols by the insurance companies
• Ensure the decisions are according to the best medical standards and agreement terms & conditions in order to prevent abuse,
• Ensuring that approvals, denials, and appeals are efficiently processed.
• Set the targets aligned with the overall forecast. Analyze, monitor the cost effectiveness of the unit and utilization of services.
• Negotiate and agree with the insurance companies for better procedures approval prices.
• 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 the organization values and business strategy
• Ensure compliance to MOH and CCHI regulations.
• Improve decision making skills on individual level.
• Process improvement initiatives to achieve excellence
• Take active part in all projects taking place and related to the organization’s main goals.
• 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 required to achieve the organizational objectives.
• Take active part in complaint management and communicate effectively (inter/intra department).
• Manage any crises effectively based on already set business continuity plan
• Following CCHI policy terms and conditions.
• Demonstrates compassionate communication skills while providing support and care to the patients as “the patient is the center of our care”.
• Coordinating the access and continuity of care for high risk patients and those requiring complex treatments
• Ensuring the implementation of evidence based practice guidelines
• Coordinates the approvals of inpatients’ additional services and treatment extensions.
• Manages additional service approvals and treatment extensions for inpatients.
  

  Other Job Functions:

  
  
• Perform all duties and tasks in line with the Person Centered Care values.
• Adherence to all policies, plans and programs within the Fakeeh Care.
• Perform duties as per the code of conduct requirement and ethical standards as outlined in the HCM policies and guidelines.
• Complete mandatory education as per the requirement at least one month prior to expiration.

JOB REQUIREMENTS / QUALIFICATIONS :

Education:

MBBS

Experience:

5 Years and above in clinical and insurance experience

Language:

English + Arabic

Required Licenses:

SCHS