Approval Specialist / Senior Approval Specialist
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Key skills for this role
About the Role
Fakeeh Care Group seeks an Approval Specialist to process medical preauthorization requests, ensuring compliance with CHI regulations and payer guidelines. The role involves verifying clinical documentation, liaising with physicians, and managing rejections.
Key Skills for This Role
Responsibilities
- Ensure full adherence to CHI Preauthorization Policy, NPHIES standards, and individual payer coverage protocols
- Verify completeness of clinical documentation and utilization of Minimum Data Set (MDS) for every request
- Review treating physician's progress notes, diagnostics, prescriptions, and clinical justifications for accuracy and adequacy
- Validate medical necessity in alignment with evidence based guidelines, CHI standards, and payer criteria
- Ensure accurate clinical coding and scheme linkage to prevent claim denials
- Liaise with treating physicians, nurses, and roving doctors to secure approvals and clarify case details
- Communicate approvals, denials, and payer queries within CHI mandated timelines
- Monitor HIS/NPHIES queues to follow up on pending or queried cases in real time
- Maintain updated approval status in both HIS and the patient's record
- Review all preauthorization rejections and categorize based on cause
- Coordinate with Preauthorization Supervisor to ensure each rejection is reviewed within assigned TAT
- Engage directly with treating physician for clarification or missing documentation related to rejected cases
Requirements
- Bachelor's degree in medicine and surgery, Pharmacy, Dental or related field
- 3–5 years clinical practice, with at least 2 years in preauthorization/insurance or utilization management
- Strong knowledge of CHI laws, preauthorization policies, and payer protocols
- Clinical judgment and ability to assess medical necessity
- High attention to detail and ability to manage high volume requests under time constraints
- Strong communication, negotiation, and documentation skills
- Excellent command of oral and written English and Arabic
Full Job Posting
Job Purpose
- To ensure timely, accurate, and compliant processing of all medical preauthorization requests for inpatient, outpatient, ER, pharmacy, and ancillary services.
- Safeguards hospital revenue by acting as a clinical and regulatory gatekeeper, ensuring medical necessity and entitlement in line with CHI regulations, NPHIES protocols, and payer specific guidelines.
- Supports operational efficiency by reducing payer denials and avoiding financial leakage.
Key Responsibilities And Duties
- Ensure full adherence to the Council of Health Insurance (CHI) Preauthorization Policy, NPHIES standards, and individual payer coverage protocols.
- Prevent unauthorized, uncovered, or non contracted services from being initiated.
- Support the implementation and compliance of NPHIES downtime contingency procedures.
- Verify the completeness of clinical documentation and utilization of the Minimum Data Set (MDS) for every request.
- Review the treating physician's progress notes, diagnostics, prescriptions, and clinical justifications for accuracy and adequacy.
- Validate medical necessity in alignment with evidence based guidelines, CHI standards, and payer criteria.
- Ensure accurate clinical coding and scheme linkage to prevent claim denials.
- Escalate incomplete or inaccurate documentation for correction prior to submission.
- Liaise with treating physicians, nurses, and roving doctors to secure approvals and clarify case details.
- Communicate approvals, denials, and payer queries within CHI mandated timelines.
- Respond to payer or insurer queries within 30 minutes of receipt.
- Escalate urgent or high priority cases (ER, ICU, Oncology, or high cost procedures) immediately to the Preauthorization Manager.
Requirements
- Strong knowledge of CHI laws, preauthorization policies, and payer protocols.
- Clinical judgment and ability to assess medical necessity.
- High attention to detail and ability to manage high volume requests under time constraints.
- Strong communication, negotiation, and documentation skills.
- 3–5 years clinical practice, with at least 2 years in preauthorization/insurance or utilization management.
- Bachelor's degree in medicine and surgery, Pharmacy, Dental or related field.
- Excellent command of oral and written English and Arabic.
- Preferred license for practice as per the regional health regulatory authority e.g. (SCFHS / DHA).
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