Manager - Medical Pre Authorisation
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Key skills for this role
Role Overview
Ensure clinically appropriate, evidence-based preauthorization decisions through utilization management, regulatory compliance, and provider engagement.
Safeguard patient outcomes, enhance customer experience, and optimize healthcare resource utilization.
Key Skills for This Role
Full Job Posting
Role Overview
Ensure clinically appropriate, evidence-based preauthorization decisions through utilization management, regulatory compliance, and provider engagement.
Safeguard patient outcomes, enhance customer experience, and optimize healthcare resource utilization.
Medical Cost and Service Management
- Apply evidence-based medicine, clinical guidelines, and policy terms during preauthorization review.
- Ensure appropriate utilization of healthcare services while preventing unnecessary costs.
- Support cost-containment initiatives through medical adjudication and utilization management.
Quality Medical Decision and Patient Safety
- Ensure clinically sound and consistent medical decisions.
- Monitor decision quality and adherence to medical protocols.
- Promote provider satisfaction through effective communication and partnership management.
Business Support and Stakeholder Management
- Manage and escalate high-value, complex, or critical cases when required.
- Participate in complaint resolution and support business continuity efforts.
- Maintain effective communication with internal and external stakeholders.
- Report operational risks and critical incidents in a timely manner.
Compliance, Governance and Risk
- Ensure adherence to company policies, medical protocols, and regulatory requirements.
- Comply with CHI regulations and governance standards.
- Identify, escalate, and report suspected fraud, waste, abuse, and anti-selection activities.
- Support audit readiness and compliance monitoring activities.
Skills and Qualifications
- Minimum three years of medical experience.
- Clinical experience as a general practitioner, emergency physician, or family medicine physician.
- Experience in medical insurance practice.
- English-language proficiency and basic computer skills.
- Bachelor’s degree in medicine or equivalent.
- Postgraduate qualification in medicine.
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