Medical Lead

1 month ago

الرياض, Saudi Arabia The Cigna Group Full time

**JOB PURPOSE**

**RESPONSIBILITIES AND DUTIES**
- Part of a clinical team that provides medical management services to customers in KSA.
- Handles most complex cases with full autonomy for decision making while identifying and resolving barriers that hinder effective patient care. Recognized internally as “the go-to person” for the most complex Health Services assignments and as a “Subject Matter Expert”.
- Provides strategic planning, and direction of a quality, cost effective delivery system providing health services to members.
- Studies trends and develops processes and procedures to ensure quality service.
- Establishes process and procedures to ensure quality programs will meet or exceed guidelines or requirements by specific assigned vendors. Responsibilities include, but are not limited to: analyzing and appraising management as to performance of vendor services using measurement criteria; collecting and analyzing data, identifying variance and unacceptable performance, and monitoring correction and ongoing compliance; providing resources and expertise in the areas of regulatory mandates, accreditation standards, and implementing quality management process policies and procedures; and managing individual case review and investigation.
- Serves as a resource/educator regarding specific areas of expertise.
- Uses deep professional knowledge and acumen to advise functional leaders on development of wellness programs for internal and external stakeholders.
- Serves as clinical advisor to the sales, client management, broker management and underwriters, by providing ongoing product and industry knowledge/education that positively influence cost, quality and customer satisfaction.
- Maintains updated knowledge of local and regional regulatory insurance mandates and clinical policies, and responsible for relaying this information to the team and relevant stakeholders.
- Assist in payment integrity by detection of fraud, waste or abuse in medical review process, with clinical advice where required.
- Manages inpatient and outpatient medical costs at levels consistent with the plan's objectives by directing the case management, medical review, utilization review, quality assurance/improvement, and/or health education programs.
- Focuses on implementing and executing strategies within own team.
- Manages the development of processes and procedures to ensure the quality of the medical review process and responsible for the performance, productivity, and quality of the clinical team.
- Other duties as assigned

**Minimum requirements**:

- Medical Master / Doctor Degree with international healthcare experience specially in KSA and Middle East region.
- 5+ years of clinical experience preferable in a payer setting on medical management.
- Experience in utilization/case management, cost containment services, managed care, insurance coverage, and financial management.
- Strong interpersonal and communication skills.
- Demonstrates pro-active problem-solving and analytical skills.
- Ability to operate a personal computer, proficient with Microsoft office products and a variety of software for medical management.
- Ability to build solid working relationships with staff, matrix partners, clients, customers and healthcare providers.
- Stress resistant and efficient, finding a good balance between quality and quantity.

**Language requirements**:

- English: read, write and speak fluently.
- Arabic is a plus.

**About The Cigna Group**

Doing something meaningful starts with a simple decision, a commitment to changing lives. At The Cigna Group, we’re dedicated to improving the health and vitality of those we serve. Through our divisions Cigna Healthcare and Evernorth Health Services, we are committed to enhancing the lives of our clients, customers and patients. Join us in driving growth and improving lives.
- Qualified applicants will be considered without regard to race, color, age, disability, sex, childbirth (including pregnancy) or related medical conditions including but not limited to lactation, sexual orientation, gender identity or expression, veteran or military status, religion, national origin, ancestry, marital or familial status, genetic information, status with regard to public assistance, citizenship status or any other characteristic protected by applicable equal employment opportunity laws._

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