Job Description
Overseeing and ensuring the integrity of quality and risk management processes across all medical activities. Will also ensure the quality of reported unaccepted critical incidents/sentinel events from TPA accounts, ensuring alignment with established quality benchmarks, identifying risks, formulating mitigation strategies, overseeing needed data documentation and management, conducting root cause analyses (RCAs), and devising implementation plans for effective resolutions. Collaboration with healthcare providers is integral to enhancing overall quality, minimizing risks, and fostering patient safety. Additionally, the incumbent will be tasked with spearheading the development and execution of quality enhancement initiatives, ensuring compliance with regulatory standards, and fostering a culture of continuous improvement in quality and risk management within the medical domain.
Total Quality and Risk Management
- Develop and implement action plans to address identified issues, ensuring appropriate interventions are put in place to prevent recurrence and improve overall quality and risk management.
- Collaborate with healthcare providers to establish effective communication channels, provide feedback on incident investigations, and work together to implement quality improvement initiatives and risk mitigation strategies.
- Manage the clinical quality for the health provision arm of the company, including collaboration with all the concerned stakeholders to monitor and improve clinical outcomes, ensuring adherence to evidence-based practices, and promoting patient-centered care.
- Identify, assess, and mitigate risks associated with healthcare services, working closely with the risk management team and other stakeholders to develop and implement risk management strategies and policies.
- Monitor compliance with regulatory standards and internal quality and risk management policies, conducting audits as necessary to identify areas for improvement and corrective actions.
- Maintain accurate and comprehensive records of incidents, investigations, resolutions, and improvement initiatives, producing regular reports for management and clients.
TPA Critical and Sentinel Events Management
- Conduct thorough root cause analysis of TPA unaccepted critical incidents/sentinel events, working collaboratively with relevant stakeholders to determine underlying causes and contributing factors.
- Take over communication regarding TPA unaccepted critical incidents/sentinel events with internal and external stakeholders from the provider management, treating doctors, Bupa teams, and regulators (e.g., Patient Safety Center SPSC) to secure all necessary documents required for case study and quality-based analysis to set a corrective action plan whenever needed.
- Follow up on cases progress with providers to monitor case management and outcomes for precise decision-making and disseminate decisions to TPA medical management team as per business requirements.
- Ensure data mining, comprehensive case validation from quality standpoint and investigations whenever needed to ensure accuracy and completeness.
- Monitor the accomplishment of all set and agreed performance guarantees with TPA accounts, generate data reports for all stakeholder groups timely on a quarterly basis and for TPA medical team on a monthly basis
Reporting, Documentation and data mining
- Generate internal reports and analyses on a monthly, quarterly, and annual basis to monitor quality assurance.
- Dynamically identify top providers based on reported unaccepted critical incidents/sentinel events, including severity categorization, specialty, region, doctor's name, rate of each category of complication, and international benchmarks collaborating with medical operations team to assess and rank providers from a quality perspective based on the provided context inclusive on whole book cases/complications.
- Archive reports/forms in hard and soft copies as per business need within the dedicated repository, segregating and follow up analysis of TPA cases for quality documentation and analysis.
- Ensure the secure storage of all the obtained information within the assigned electronic platform/data warehouse, adhering to quality management principles, regulatory standards, ensuring worldwide recognized codes of ethics and patient confidentiality rules
Skills
A medical degree (MBBS, MD or equivalent). Strong knowledge of healthcare operations, clinical practices, healthcare laws and regulations, healthcare accreditation and quality and risk management principles are essential.
Relevant quality certifications, such as Certified Professional in Healthcare Quality (CPHQ) or similar, demonstrating expertise in quality management methodologies and frameworks.
Certifications in risk management, such as Certified Professional in Healthcare Risk Management (CPHRM) or equivalent, showcasing proficiency in identifying and mitigating healthcare risks.
Strong analytical and problem-solving skills/certificates, with the ability to conduct root cause analysis, interpret complex data, and develop evidence-based strategies for quality improvement and risk mitigation.
Excellent communication and interpersonal skills, with the ability to collaborate effectively with internal and external stakeholders, including healthcare providers and clients.
Exhibit strong leadership capabilities, including the ability to motivate and inspire teams, drive change, and influence stakeholders at all levels of the organization. Ability to develop consensus and promote teamwork.
Advanced level in working with Word, Excel, PowerPoint, MS Power BI, Access databases, etc. Familiarity with various software, equipment, and technology necessary to provide medical services. Knowledge of Data Analysis and Healthcare Analytics to cater for an ever-changing health care environment
Education
Medicine
