Approval Officer

Overview

• 2.1 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.
• Evaluate pre-approval requests for medical necessity of the requested services based on medical data provided and accurately code service descriptions stated on prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and policy schedule of benefits.
• Respond to insurance/TPA queries and liaise with concerned departments without delay.
• Receive, evaluate, and escalate second opinion cases and case management referrals as required.
• Perform night shift duties and work on public holidays as per duty roster.
• Prepare daily activity reports as requested by management and assist in monthly reporting requirements.
• Handle the auditing process by arranging required documents and coordinating with coders to support external auditors.
• Attend meetings and presentations as required.
• Train front office staff, receptionists, and nurses, and keep them updated on insurance-related processes and requirements.
• Prepare cost estimates for procedures for cash patients.
• Adjust duties in case of sudden or emergency unplanned leave by colleagues.
• Manage and hand over pending cases, if any, to the next shift colleagues.
• Perform any other duties assigned by the HOD from time to time within the scope of the job title.
• Comply with all OSH and infection control policies, standards, and procedures, and cooperate with hospital management to ensure compliance.
• Work in accordance with documented OSH procedures and instructions, including specific responsibilities.
• Be familiar with emergency and evacuation procedures.
• Report OSH hazards, incidents, near misses, and issues, and assist in the preparation of risk assessments and incident reports.
• Comply with waste management procedures and policies.
• Attend applicable OSH and infection control training programs, mock drills, and awareness programs.
• Use appropriate personal protective equipment and safety systems at all times.
• Bachelor’s Degree in Medicine (MBBS) from a recognized university.
• Minimum 2 years of experience in insurance claims management and/or adjudication.
• Experience in medical coding including ICD, CPT, DRG, and HCPCS.
• Excellent command of spoken and written English.
• Flexible and able to work under pressure.
• Strong knowledge of Microsoft Office applications.