Job Description

DUTIES AND RESPONSIBILITIES

1. 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.

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

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

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

5. Attend Meetings and Presentation.

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

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

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

• Evaluate pre-approval requests for medical necessity of the requested services based on the medical information provided, and accurately assign service description codes on prior authorization requests in accordance with accepted medical coding standards, medical guidelines, and policy schedule of benefits.
• Respond promptly to insurance/TPA queries and coordinate with the concerned departments without delay.
• Receive, evaluate, and escalate second opinion and case management requests as required.
• Prepare daily activity reports as requested by management and assist in preparing monthly reports.
• Attend meetings and presentations as required.
• Adjust and support operational duties in case of sudden or emergency unplanned leave by colleagues.
• Manage and hand over pending cases, if any, to the next shift colleagues to ensure continuity of work.
• Perform any other duties assigned by the HOD from time to time within the scope of the job title.

• Bachelor’s degree in Medicine or an equivalent medical degree from a recognized university.
• Minimum 2 years of experience in insurance claims management and/or adjudication.
• Knowledge of medical coding systems including ICD, CPT, DRG, and HCPCS.
• Excellent command of written and spoken English.
• Flexible and able to work under pressure and in shift-based environments.
• Strong proficiency in Microsoft Office applications.