Manager - Medical Pre Authorisation

Manager – Medical Pre-Authorisation

Join our dynamic healthcare team as a **Manager – Medical Pre-Authorisation**, where you will play a pivotal role in ensuring clinically sound, evidence-based pre-authorisation decisions that drive operational excellence, enhance patient outcomes, and optimise healthcare resource allocation. This strategic position demands a blend of clinical expertise, analytical rigor, and exceptional stakeholder management to uphold regulatory compliance, mitigate risks, and foster seamless collaboration across internal and external partners.

In this leadership role, you will oversee the entire pre-authorisation process, balancing clinical integrity with cost-effectiveness while maintaining the highest standards of patient safety and provider satisfaction. Your strategic decision-making will directly influence healthcare delivery, ensuring that medical services are authorised in alignment with best practices, regulatory frameworks, and organisational policies.

Key Responsibilities

Your responsibilities will span across **medical cost management, clinical decision-making, business support, and compliance governance**, requiring a holistic approach to optimise healthcare outcomes:

• Medical Cost & Service Management
  - Apply rigorous clinical guidelines, evidence-based medicine, and policy frameworks to evaluate pre-authorisation requests, ensuring adherence to medical necessity and cost-efficiency standards.
  - Actively contribute to cost-containment initiatives by implementing effective medical adjudication and utilisation management strategies, reducing unnecessary expenditures without compromising patient care.
  - Collaborate with cross-functional teams to align pre-authorisation processes with broader healthcare financial objectives, fostering a culture of responsible resource utilisation.
• Quality Medical Decision & Patient Safety
  - Lead the development and enforcement of consistent, clinically robust decision-making protocols to ensure high-quality pre-authorisation outcomes.
  - Monitor and evaluate decision quality, identifying trends and areas for improvement while maintaining strict adherence to medical protocols and regulatory standards.
  - Strengthen provider relationships through transparent communication, proactive engagement, and partnership-building, ensuring alignment with organisational goals and clinical best practices.
• Business Support & Stakeholder Management
  - Assume ownership of high-value, complex, or critical pre-authorisation cases, escalating them as necessary to resolve disputes and maintain operational continuity.
  - Act as a key liaison between internal teams (e.g., medical review, finance, and compliance) and external stakeholders, including healthcare providers, insurers, and regulatory bodies.
  - Promptly report operational risks, critical incidents, and compliance concerns to mitigate potential disruptions and ensure timely resolution of complaints.
• Compliance, Governance & Risk Management
  - Ensure full compliance with **Bupa’s medical policies, clinical protocols, and regulatory requirements**, including **CHI governance standards and anti-fraud measures**.
  - Proactively identify, escalate, and report suspected instances of fraud, waste, abuse, and anti-selection activities to safeguard organisational integrity.
  - Support audit readiness initiatives by maintaining comprehensive documentation and facilitating compliance monitoring activities to uphold regulatory adherence.

Skills & Qualifications

To excel in this role, you will bring a robust blend of **clinical expertise, leadership acumen, and operational insight**, coupled with a commitment to continuous improvement:

• Clinical Experience
  - Minimum **3 years of specialised experience** in medical pre-authorisation, medical insurance, or healthcare utilisation management.
  - Proven background as a **General Practitioner, Emergency Medicine Specialist, or Family Medicine Practitioner**, with hands-on experience in hospital-based or insurance-related healthcare settings.
  - Strong understanding of **evidence-based medicine, clinical guidelines, and medical adjudication processes**.
• Education & Certification
  - **Bachelor’s degree in Medicine or equivalent**, complemented by a **Postgraduate qualification in Medicine and Surgery**.
  - Valid medical licensing and registration in compliance with local healthcare regulations.
• Technical & Soft Skills
  - Proficiency in **English (written and verbal)** and basic computer skills, with experience using medical software, databases, and compliance tracking tools.
  - Exceptional **analytical, problem-solving, and stakeholder management skills**, with the ability to navigate complex healthcare landscapes.
  - Strong **leadership and communication abilities**, enabling effective collaboration with multidisciplinary teams and external partners.

This is an opportunity to make a meaningful impact on healthcare delivery while advancing your career in a **fast-paced, results-driven environment**. If you are a clinically astute leader with a passion for optimising healthcare resources and ensuring patient-centric decision-making, we invite you to apply and contribute to our mission of excellence in medical pre-authorisation.