Role summary
Adjudicate inpatient and outpatient pre-authorization requests accurately and within approved clinical, regulatory, and policy standards, controlling medical expenditure while safeguarding member health and safety in line with Bupa values.
Responsibilities
- Adjudicate inpatient and outpatient pre-authorization cases in line with common medical practice, Bupa protocols, and policy
- Apply the client agreement terms and conditions when reviewing each case
- Make consistent, clinically sound decisions based on approved clinical and practice guidelines
- Safeguard member health and safety throughout the pre-authorization process
- Adjudicate cases promptly to maintain a responsive service to hospitals and members
- Manage case volumes to sustain productivity and turnaround
- Process authorizations in line with company policy and applicable regulations
- Escalate high-value transactions and claims through the agreed process
- Identify and report suspected fraud, abuse, and anti-selection through the agreed channels
- Contribute to medical and operational projects that improve the pre-authorization function