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Manager – Commercial Medical Management
Hiba International Recruitment
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 Vacancy No: HIBA-01346
 No. of Post: 1
 Duty Station: KSA
 Closing Date: 12 Oct 2014

 
 Background:

Managing the mega account groups loss ratio by holding down their claims experience; achieved by proactively providing the clients with insight and recommended actions so their members receive the most appropriate treatment in line with the best cost effectiveness medical practice and provide clear healthcare service differentiation. The desired outcomes are both improved contribution and increasing the retention rate.



 
 Duties and responsibilities:

#

Key Accountabilities

Key Activities / Decision Areas

1

  • Commercial analysis
  • Conduct monthly analysis by group  to comprehend their claims experience and behaviour
  • 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).
  • 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.  
  • Analyse, monitor the cost effectiveness of the unit and utilization of services of the providers.
  • 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.
  • Prepare periodically presentation to the group in order to inform, coach and lead the group to understand their experience with Bupa.
  • 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.

 

2

  • Medical consultancy

 

  • Build a strong partnership / affinity with the group secretary by being the reference point for their medical /service query.
  • 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.
  • 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.
  • 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. 
  • Reporting to the medical director and the provider relation team any case of malpractice and medical complications.
  •  

3

  • Healthcare partnership
  • 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)
  • Where appropriate arrange Outreach programs with Groups/Customers to promote healthcare partnership and wellness agenda (health lounges , Seminars) 
 

 
 Minimum Qualification, Skills and Experience Required:

Person Specification

Education

  • Medical Qualification (MBBS, MBChB or equivalent)

Experience Fields

  • Experience in medical insurance practice
  • Experience in risk assessment and management 
  • Strong data analysis skills
  • Product management
  • Strong presentation and negotiation skills
  • Comprehensive knowledge in Bupa products and services

Years of Experience 

  • 2 years
 

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