Onsite Claims Management Manager

About the role

The Onsite Claims Management Manager ensures that inpatient claims submitted by providers are medically and commercially adjudicated directly within the hospital, meeting quality and timeliness targets to support BUPA’s high‑standard claim processing.

Key responsibilities

• Adjudicate assigned providers’ inpatient claims onsite the hospital within specified timeframes and quality standards.
• Review and process all IP cases in line with medical policy, invoice line items and inpatient adjudication guidelines.
• Make decisions that adhere to medical standards and contract terms, preventing abuse, fraud and overtreatment.
• Follow a detailed checklist: verify physical or scanned claims, cross‑check with electronic data from Edge, hospital systems and management, and record decisions in the operations system.
• Achieve daily claim volume targets and maintain at least 95% accuracy on quality audits.
• Escalate high‑value or complex claims to the onsite claims manager and discuss challenging decisions with the medical manager.
• Collaborate with hospital management to resolve IP claims issues and foster partnership relationships.
• Identify abnormal provider trends, detect and forward fraud, waste and abuse cases, and monitor provider performance monthly.
• Support team capability building by sharing knowledge, providing feedback and assisting colleagues.
• Rove between assigned hospitals, being present onsite as needed to ensure continuous claim processing.

Required profile

• Clinical experience in a healthcare setting.
• Experience with medical insurance claim processes.
• Education: MBBS (Bachelor of Medicine & Surgery) or equivalent.

Required skills