Manager - Medical Pre Authorisation

Manager - Medical Pre Authorisation

Join our dynamic 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 optimal healthcare outcomes, enhance patient experiences, and streamline resource allocation. In this strategic position, you will bridge the gap between clinical excellence, regulatory compliance, and operational efficiency, fostering a culture of accountability and continuous improvement within our healthcare ecosystem.

As a key decision-maker, you will leverage your deep expertise in medical adjudication to evaluate pre-authorisation requests with precision, ensuring adherence to clinical guidelines, evidence-based medicine, and policy frameworks. Your role extends beyond mere approvals—you will actively contribute to cost-containment strategies by identifying opportunities to optimize healthcare service utilization while safeguarding patient safety and quality of care. Through meticulous review processes, you will mitigate unnecessary expenditures without compromising clinical integrity, aligning financial responsibility with patient-centric outcomes.

Core Responsibilities

Your responsibilities will encompass a broad spectrum of critical functions, including:

• Clinical Decision-Making and Utilization Management: Apply rigorous clinical judgment to assess pre-authorisation requests, ensuring decisions are grounded in the latest medical evidence, guidelines, and regulatory standards. Collaborate with cross-functional teams to refine utilization management practices that balance cost-effectiveness with high-quality care.
• Quality Assurance and Patient Safety: Champion consistency and excellence in medical decision-making by monitoring adherence to clinical protocols and best practices. Act as a trusted advisor to providers, fostering transparent communication and collaborative partnerships to enhance satisfaction and trust in the pre-authorisation process.
• Stakeholder Engagement and Case Management: Lead the resolution of complex, high-value, or time-sensitive cases, escalating as necessary to ensure timely and appropriate outcomes. Serve as a liaison between internal teams, external providers, and regulatory bodies, maintaining open channels of communication to address concerns and mitigate operational risks.
• Compliance and Regulatory Adherence: Uphold the highest standards of compliance with Bupa’s internal policies, CHI regulations, and governance frameworks. Proactively identify and escalate potential risks, including fraud, waste, abuse, or anti-selection activities, while supporting audit readiness and ongoing compliance monitoring efforts.
• Business Continuity and Risk Mitigation: Contribute to complaint resolution processes and business continuity planning to ensure resilience in the face of disruptions. Provide timely reporting on operational risks and critical incidents to enable proactive interventions and strategic decision-making.

This role is ideal for a seasoned professional with a passion for integrating clinical expertise with operational strategy. You will thrive in an environment that values innovation, collaboration, and a commitment to delivering exceptional healthcare solutions. If you are a detail-oriented leader with a proven track record in medical insurance, clinical governance, and stakeholder management, we invite you to take the next step in your career with us.

Qualifications and Experience

To excel in this position, you will bring:

• A minimum of **three years of relevant experience** in medical pre-authorisation, utilization management, or a related clinical field.
• Proven expertise as a **General Practitioner, Emergency Physician, or Family Medicine specialist**, with a strong foundation in medical insurance practices.
• A **Bachelor’s degree in Medicine** or an equivalent qualification, complemented by a **postgraduate certification in Medicine** to ensure advanced clinical acumen.
• Proficiency in **English** and basic computer skills, with the ability to navigate specialized medical and administrative software.
• Exceptional analytical and communication skills, coupled with a commitment to ethical standards and regulatory compliance.

This opportunity is designed for individuals who are not only clinically adept but also strategic thinkers capable of driving systemic improvements in healthcare delivery. If you are ready to make a meaningful impact in medical pre-authorisation and utilization management, we encourage you to apply.