Outpatient (OP) Medical Board Executive
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Key skills for this role
About the Role
GIG Gulf seeks an Outpatient Medical Board Executive to assess and evaluate pre-approval requests for medical eligibility and policy terms. The role involves adjudicating insurance pre-approvals, cost containment, and fraud management.
Key Skills for This Role
Responsibilities
- Adjudicate and process insurance pre approvals in a timely and accurate manner following company policy terms and conditions
- Provide preapproval for medical claims based on medical eligibility and policy terms
- Contribute to cost containment through GIG Guidelines and proper medical adjudication
- Contribute to Fraud Waste and Abuse management in the pre approval function
- Assist team leaders in Queue management and Customer care email management as required on adhoc basis
- Decide on pre approval based on medical necessity and internationally accepted medical guidelines
- Report provider abuse if recurrent as part of cost containment strategy
- Validate approvals for junior staff
- Perform case management within the scope of Outpatient approvals with enhanced member experience and savings
Requirements
- Minimum 3 5 years experience in Medical Insurance Pre approval Process
- Medical Coding Certification from AAPC/AHIMA
- Medical / Dental / Nursing Degree
- Flexibility to work in different shifts (24x7)
- Regional experience and working knowledge of healthcare regulations in UAE, Bahrain, Oman & Qatar
- Sound medical knowledge
- Good analytical skills
- Experience in Outpatient Medical Coding and Billing
- Strong communication (verbal & written)
- Ability to work effectively within a team environment
- Highly motivated and proactive
- Results driven and solution oriented
Full Job Posting
Who we are
- GIG Gulf is part of Gulf Insurance Group, the #1 largest regional composite insurer in MENA, with presence in 12 markets.
- GIG Gulf is an 'A' rated regional insurer with a top 5 position in UAE, Oman, Qatar, Bahrain.
- GIG Gulf has over 800 employees, 60 nationalities, 15 branches, and over 1 million customers.
Job purpose
- To assess and evaluate preapproval requests from providers in terms of medical eligibility and policy terms, providing World Class Customer Service.
Key Responsibilities
- Adjudicating and Processing insurance pre approvals in a timely and accurate manner following Company policy terms and conditions.
- Providing preapproval for medical claims based on medical eligibility and policy terms.
- Contribution in cost containment through GIG Guidelines and proper medical adjudication.
- Contribution in Fraud Waste and Abuse management in the pre approval function.
- Assist team leaders in Queue management, Customer care email management as required on adhoc basis.
Operational & Technical Responsibilities
- Sound knowledge of medical and insurance guidelines.
- Ability to understand different aspects of the Healthcare Platform to direct queries to relevant parties.
- Requires detailed understanding of reasons for inclusion/exclusion of certain treatments or conditions.
- Sound knowledge of regulations from a regulatory authority.
- Independent thought and judgment to evaluate medical decisions on an objective basis.
- Decide on pre approval based on medical necessity and internationally accepted medical guidelines.
- Reporting of provider abuse if recurrent as part of cost containment strategy.
- Individual quality monitoring, identifying and reporting opportunities for Quality improvement.
- Able to validate approvals for junior staff.
- Case management within scope of Outpatient approvals with enhanced Member experience and Savings.
Requirements
- Minimum 3 5 years experience in Medical Insurance Pre approval Process.
- Medical Coding Certification from AAPC/AHIMA.
- Medical / Dental / Nursing Degree.
- Flexibility to work in different shifts (24x7).
- Regional experience and working knowledge of healthcare regulations in UAE, Bahrain, Oman & Qatar.
Desirable
- Sound medical knowledge.
- Good analytical skills.
- Experience in Outpatient Medical Coding and Billing.
- Strong communication (verbal & written).
- Ability to work effectively within a team environment.
- Highly motivated and proactive.
- Results driven and solution oriented.
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