Manager - Clinical Excellence
- المدينة
- الخبر
- نوع العمل
- حضوري
- تاريخ النشر
- نُشرت أمس
- المجال
- القطاع الصحي
عن الوظيفة
To manage inpatient cases onsite and across the care journey, ensuring care is clinically appropriate, of high quality, patient-centered and cost-efficient. Medical Outcomes Management and Monitoring · Apply evidence-based clinical guidelines and protocols to inpatient cases. · Conduct clinical case reviews for medical necessity and appropriateness.
· Manage complex and high-risk cases, escalating where required. · Assess care pathways, quality of care and outcomes across internal and external care channels. Conduct medical FIs and hospital profiling. Patient-Centric Service · Apply patient- and member-centric principles in clinical care management processes.
اقرأ الوصف كاملاً
· Balance clinical appropriateness, cost efficiency and customer experience in care decisions. · Conduct proactive engagement with high-risk and chronic patients to improve experience and outcomes. · Coordinate with onsite and third-party providers on quality checks and documentation, and address failures promptly.
Support third-party customer relationship management programmes. Utilization & Cost Management · Review admission appropriateness and level of care. · Review inpatient utilisation promptly, within the agreed standards of the inpatient end-to-end management programme. · Monitor length of stay and support discharge planning.
· Identify high-cost cases and recommend interventions and cost-containment initiatives. · Audit and report fraud, coding abuse and non-compliance with coding standards. Onsite Adjudication · Verify, audit and report all inpatient services incurred.
· Review and process inpatient claims onsite against medical policy, line items, invoices and adjudication guidelines, cross-checking physical and electronic claims data. · Apply medical judgement and agreement terms and conditions to prevent abuse, fraud and overtreatment. · Escalate high-profile and high-value claims for decision.
· Coordinate with hospitals to resolve inpatient claim issues. Quality Management · Apply quality standards across clinical care management. · Conduct clinical quality assurance and quality control checks. · Monitor adherence to clinical guidelines, protocols and regulatory requirements.
· Track quality indicators in daily operations and recommend improvements that standardise clinical practice. · Document clinical decisions to support audit and compliance. Job Details Posted Date: 2026-10-19 Job Location: Saudi Arabia - Khobar Job Role: Doctors Preferred Candidate Career Level / Band: Entry Level Minimum Degree: Bachelor's degree