Job Description

1. Evaluate the pre-authorization requests from medical necessity for the requested service according to the medical data provided and accurately code the service description codes stated on the prior authorization requests, according to accepted medical coding rules, medical guidelines and policy’s schedule of benefits

2. Response to Insurance/ TPA queries and liaise with concerned department.

3. Responsible for receiving, evaluating and escalating second opinion cases and case management.

4. Perform night shift duty to sustain any issues and queries related to Authorization department.

5. Prepares reports of daily activity as requested for management and assists management in monthly reports as requested.

6. GENERAL RESPONSIBILITIES:

1. Work in all shifts as scheduled by the Head of Department.

   1. Strictly adheres to organization’s regulations and policies especially those related

to infection control, patient safety, OSHMS, DOH, JCI and ISO.

2. Supports Continuous Quality Improvement and participates and contributes to all

   the quality assurance activities of the service.

   1. Participates and contributes in scheduled in-service training programs.

   2. Exercises effective interpersonal skills in dealings with department staff, associates

and Management.

3. Maintains confidentiality as per the agreement signed.

   1. Demonstrates the ability to listen to others in promoting effective communication.

   2. Develops thorough understanding of policies and procedures of the hospital and

demonstrates respect for them.

4. Carries out other duties when requested by the Head of department.

• Evaluate the Pre Approval requests from medical necessity for the requested service according to the medical data provided and accurately code the service description codes stated on the prior authorization requests, according to accepted medical coding rules, medical guidelines and policy’s schedule of benefits.

• Respond to Insurance/ TPA queries and liaise with concerned department without any delay.

• Responsible for receiving, evaluating and escalating second opinion cases and case management.

• Perform night shift duty and on public holidays as per duty roster.

• Prepares reports of daily activity as requested for management and assists management in monthly reports as requested.

• Handle Auditing Process. Arrange required documents and papers and check with coders in order to assist the external Auditors.

• Attend Meetings and Presentation.

• Train Front office, Receptionist and Nurses and keep them updated about Insurance details.

• Prepare cost estimate for procedures for Cash Patient.

• To adjust duties in case of any sudden/ emergency unplanned leaves by colleagues.

• Managing and handling pending cases (if any) to the next shift colleagues.

• Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.

• Comply with all OSH and infection control policies, standards and procedures and cooperate with hospital management to comply those requirements.

• Work accordance with the documented OSH procedures and instructions, specific responsibilities.

• Be familiar with emergency and evacuation procedures.

• Notifying OSH Hazards, incidents, Near misses and issues and assistance with the preparation of risk assessments, incident reports.

• Comply with Waste management procedures and policies.

• Attend applicable OSH/Infection control training programs, mock drills and awareness programs.

• Use of appropriate personal protective equipment and safety systems.

• 
  Bachelor Degree in Medicine (MBBS) graduate from a recognized university.

• Experience in Insurance Claims management/adjudication (minimum 2 years).

• Experience in Medical Coding ICD, CPT, DRG and HCPCS.

• Excellent command of oral and written English.

• Flexible and able to work under pressure.

• Excellent knowledge of Microsoft applications.