Claims Officer (Pre-Authorization) - Insurance TPA
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Key skills for this role
About the Role
Dubai Insurance TPA is seeking a Claims Officer for pre-authorization in Dubai Silicon Oasis. The role involves reviewing and approving medical services based on medical necessity guidelines.
Key Skills for This Role
Responsibilities
- Review and approve medical services requested by providers or customers according to medical necessity review guidelines
- Give evidence based advice on pre authorization, considering internationally accepted protocols and local/regional customs and regulations
- Assess pre authorization requests claims in line with policy coverage and medical necessity
- Identify and refer cases to the Cigna Clinical Programs team for case management, disease management and other clinical services
- Assist in coordination of processes for improving quality of care and health outcomes
- Assist and support the team in cost containment, assist in projects and service delivery to meet goals
- Assist queries from providers and payers via phone calls or e mails
- Be fully versed with medical insurance policies for various groups / beneficiaries
- Assist in fraud detection
- Meet defined qualitative and quantitative key performance metrics
- Ensure adherence to predefined TATs for pre approvals
- Achieve required targets assigned by team leader on daily, weekly, and monthly basis
Requirements
- University degree of Medical / Para medical specialization
- 2 3 years of clinical experience preferable in a payer setting on medical management
- Strong interpersonal and communication skills
- Ability to operate a personal computer, proficient with Microsoft office products
- Knowledge of utilization/case management, cost containment services, managed care, insurance coverage, and financial management a plus
- Ability to speak, write and read English
- Flexible to work on shifts/team schedule
Full Job Posting
Job Purpose
- The job holder for preauthorization is responsible to review and approve medical services requested by providers or customers according to medical necessity review guidelines.
Responsibilities and Duties
- Part of a clinical team that provides medical management services to customers worldwide but mainly in Middle East and Africa region.
- Give evidence based advice on pre authorization, considering internationally accepted protocols and local and/or regional customs and regulations.
- Assessing pre authorization requests claims in line with the policy coverage and medical necessity.
- Identify and refer cases to the Cigna Clinical Programs team for case management, disease management and other clinical services.
- Assist is the coordination of processes for improving quality of care and health outcomes for specifically delineated projects or populations.
- Assist and support the team in cost containment, assist in projects and service delivery to meet goals.
- To assist queries from providers and payers via phone calls or e mails
- Be fully versed with medical insurance policies for various groups / beneficiaries.
- Might be required to assist in training colleagues and sharing knowledge.
- Ability to review, investigate, and respond to external and internal inquires/complaints and provide guidance to other clinical and non clinical staff related to medical necessity.
- Assist in fraud detection
- Meeting the defined qualitative and quantitative key performance metrics for the assigned job role.
Knowledge, Skills and Experience
- University degree of Medical /Para medical specialization with international healthcare experience.
- 2 3 years of clinical experience preferable in a payer setting on medical management.
- Strong interpersonal and communication skills.
- Ability to operate a personal computer, proficient with Microsoft office products, call centre software and a variety of software for medical management.
- Knowledge of utilization/case management, cost containment services, managed care, insurance coverage, and financial management a plus.
- Ability to build solid working relationships with staff, matrix partners, clients, customers, and healthcare providers.
- Demonstrates pro active problem solving and analytical skills
- Stress resistant and efficient, finding a good balance between quality and quantity
- Ability to speak, write and read English, any other language a plus
- Flexible to work on shifts/team schedule
Compensation
- Pay: AED7,000.00 per month
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