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Duties and responsibilities:
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Key Accountabilities
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Key Activities / Decision Areas
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1
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Conduct monthly analysis by group to comprehend their claims experience and behaviour
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Create a monitoring dashboard for the group to understand the trends of utilization and consumption with clear warning signs (top frequent users, major medical conditions, top used providers).
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Identifying the nature of risk for each group (member fraud, provider over utilization) and agreeing with the relationship manger and the group secretary on immediate corrective actions to protect the client from excess claims which will inflate their following year premium.
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Analyse, monitor the cost effectiveness of the unit and utilization of services of the providers.
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Analyse the approved preauthorizations and claims data by group , transform data in a meaningful format to the customers and to set a group of actions to proactively manage the group performance from commercial aspect and a healthcare aspect.
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Prepare periodically presentation to the group in order to inform, coach and lead the group to understand their experience with Bupa.
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Be an integral part of the renewal negotiation with the group, where value adding. For sensitive accounts, walk hand in hand with the group relationship manager to secure the account and increasing the retention rate by the end of the underwriting year.
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2
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Build a strong partnership / affinity with the group secretary by being the reference point for their medical /service query.
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Proactively involving the group about their medical and claim performance and the best way to manage their portfolio to contain any major risk to control the high loss ratio.
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Segmenting the group profile according to the chronic illnesses (diabetes, hypertension,...etc.) and agree with the group’s key person on proactive action plan to manage the frequency of visits.
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Detecting the major high value cases (cancer cases, new born, RTA,..) and making sure they are receiving the best medical management with the best cost effectiveness providers.
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Reporting to the medical director and the provider relation team any case of malpractice and medical complications.
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3
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Coordinate internally between the different Bupa departments to assure delivering of high quality services.(providing HCO, with list of pregnant ladies for maternity coaching , chronic disease for refill medications programme , etc)
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Where appropriate arrange Outreach programs with Groups/Customers to promote healthcare partnership and wellness agenda (health lounges , Seminars)
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