Approval Officer

Job Description

Apply medical knowledge and best insurance practice while reviewing and verifying the Pre Approval requests (OP/ IP) received from different departments to obtain authorizations as required by insurance companies dependent upon the plan coverage for all Insurance patients. Ensure that the details of the Pre Authorization Requests are in line with the regulators’ standards especially the claim adjudication Rules and Business Rules.

2.2 Handling the rejected pre authorization and get required justification from the treating doctor to resend it to Insurance Company and obtain the approval.

2.3 Prepares reports of daily activity as requested for management and assists management in month end reporting as requested.

3.0 DUTIES AND RESPONSIBILITIES

1. Evaluate the Pre Approval requests from medical necessity for the requested service according to the medical data provided and accurately code the service description codes stated on the prior authorization requests, according to accepted medical coding rules, medical guidelines and policy’s schedule of benefits.

2. Respond to Insurance/ TPA queries and liaise with concerned department without any delay.

3. Responsible for receiving, evaluating and escalating second opinion cases and case management.

4. Prepares reports of daily activity as requested for management and assists management in monthly reports as requested.

1. Attend Meetings and Presentation.

1. To adjust duties in case of any sudden/ emergency unplanned leaves by colleagues.

1. Managing and handling pending cases (if any) to the next shift colleagues.

1. Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.

Responsibilities

• Apply medical knowledge and best insurance practices while reviewing and verifying OP/IP Pre-Approval requests received from different departments to obtain authorizations as required by insurance companies, based on plan coverage for all insurance patients.

• Ensure that Pre-Authorization request details comply with regulatory standards, particularly claim adjudication rules and business rules.

• Handle rejected Pre-Authorization requests and obtain the required justification from treating doctors before resubmitting them to insurance companies for approval.

• Evaluate Pre-Approval requests for medical necessity based on the medical data provided.

• Accurately code service description codes mentioned in Pre-Authorization requests in accordance with accepted medical coding rules, medical guidelines and the policy's schedule of benefits.

• Respond to Insurance/TPA queries and coordinate with the concerned departments without delay.

• Receive, evaluate and escalate second opinion cases and case management requests.

• Prepare daily activity reports as requested by management and assist with monthly reporting.

• Attend meetings and presentations as required.

• Adjust duties and responsibilities to cover colleagues' sudden or emergency unplanned leaves.

• Manage and hand over pending cases, if any, to colleagues on the next shift.

• Perform any other duties assigned by the HOD from time to time within the scope of the job title.

Qualifications

• Bachelor's degree in Medicine or equivalent medical degree from a recognized university.

• Minimum 2 years of experience in Insurance Claims Management/Adjudication.

• Knowledge of Medical Coding, including ICD, CPT, DRG and HCPCS.

• Excellent command of spoken and written English.

• Flexible and able to work under pressure and in shifts.

• Excellent knowledge of Microsoft applications.