Job Description

JOB SUMMARY

2.1 Apply medical knowledge and best insurance practice while reviewing and verifying the Pre Approval requests (OP/ IP) received from different departments to obtain authorizations as required by insurance companies dependent upon the plan coverage for all Insurance patients. Ensure that the details of the Pre Authorization Requests are in line with the regulators’ standards especially the claim adjudication Rules and Business Rules.

2.2 Handling the rejected pre authorization and get required justification from the treating doctor to resend it to Insurance Company and obtain the approval.

2.3 Prepares reports of daily activity as requested for management and assists management in month end reporting as requested.

3.0 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.

• Apply medical knowledge and best insurance practices while reviewing and verifying Pre-Approval requests (OP/IP) received from different departments to obtain authorizations as required by insurance companies, depending on the plan coverage for all insurance patients.
• Ensure that Pre-Authorization Requests comply with regulatory standards, particularly claim adjudication rules and business rules.
• Handle rejected Pre-Authorization requests and obtain the required justification from the treating doctor for resubmission to the insurance company and approval.

• Prepare daily activity reports as requested by management and assist with month-end reporting as required.

DUTIES AND RESPONSIBILITIES

• Evaluate Pre-Approval requests for medical necessity based on the medical information provided.
• Accurately code service description codes stated on prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and the policy schedule of benefits.
• Respond to Insurance/TPA queries and liaise with concerned departments without delay.
• Receive, evaluate, and escalate second-opinion cases and case management requirements as appropriate.
• Prepare daily activity reports and assist with monthly reporting as required.
• Attend meetings and presentations as required.
• Adjust and manage duties in the event of sudden, emergency, or unplanned leave of colleagues to ensure continuity of operations.
• Manage and hand over pending cases, if any, to colleagues in the next shift.
• Perform any other duties or responsibilities 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/adjudication.
• Knowledge of medical coding systems, including ICD, CPT, DRG, and HCPCS.
• Excellent command of both written and spoken English.
• Flexible and able to work under pressure and in shifts.
• Proficiency in Microsoft Office applications.