Job Description

Managerial Responsibilities:

1. Contribute to the achievement of the strategic objectives of the sector through performing own responsibilities and managing direct reports performance.
2. Set the department’s goals and objectives and ensure the cascading of such to reporting sections, and guide their achievement.
3. Contribute to the development of the sector’s policies, procedures and processes through providing input as advised by the direct supervisor.
4. Provide direction and advice to the direct reports in performing their delegated responsibilities.
5. Ensure the ongoing development of the department’s employees, and assure the developmental activities of direct reports.
6. Oversee the overall performance of direct reports and ensure KPI’s are well communicated and monitored.
7. Ensure effective identification, allocation and utilization of the division’s resources

Functional Responsibilities:

• Overseeing the review and approval process of medical service requests, ensuring clinical appropriateness and compliance with medical guidelines and regulatory requirements.
• Acts as a key liaison between medical providers, internal departments, and regulatory bodies to ensure timely and accurate decision-making regarding patient care approvals.
• Supervise and manage the medical pre-authorization and approval team.
• Review and assess medical service requests based on clinical guidelines, policies, and patient medical history.
• Collaborate with physicians, case managers, and claims departments to ensure accurate evaluations.
• Ensure compliance with internal protocols, payer policies, and relevant healthcare regulations.
• Train and support staff on clinical policies, coding, and documentation standards.
• Implement quality assurance processes for approval decisions and maintain high service standards.
• Resolve escalated cases and appeals in collaboration with the medical review board or medical director.
• Generate and analyze reports related to approval trends, turnaround times, and denial reasons.
• Prepare reports for hospital administration on approval process outcomes and compliance metrics.
• Conduct regular audits and assist in implementing corrective actions as needed.

Competencies

Behavioral/Leadership

Level

Decision Making

Leverages available information related to own area of work to handle ambiguous work situations and arrive at an appropriate solution

Generate Ideas

Adopts new ways of conducting BAU thereby creating agility and moving away from traditional methods of operation.

Strategic Direction

Drives external orientation and understands developments in the healthcare space that impact strategic plans for the section/sub-department

Develops Talent

Takes steps to build team capability by identifying learning opportunities, such as providing exposure to varied work areas, adding responsibility by way of job enrichment etc.

KPIs

Approval Turnaround Time : Measure the average time taken to process and approve new services or programs

Compliance Rate: Percentage of approvals that meet regulatory standards and guidelines on the first submission.

Audit Findings: Number of compliance issues or discrepancies identified during internal audits over a specific period.

Stakeholder Satisfaction: Feedback scores from internal stakeholders (e.g., department heads, medical staff) regarding the approval process and communication effectiveness.

Job Specifications

Minimum Job Qualifications Requirement (Academic, Certifications, languages, etc.)

• Bachelor’s degree in a relevant field

Minimum Work Experience:

5-8 years’ experience in healthcare including 2 years in a managerial role.