Job Description

Job Family Summary

The Operations Department is responsible to manage all aspects of claims management including Onsite operations and back-end processing. The department primarily works on main objective of submitting the claims in time with highest quality to ensure the client receives the payment with minimal or no rejections.

Preapproval Department is based at the hospital site which manages precertification for all OPD, IPD and EPD cases for insured members contracted with the hospital as per designated networks.

Major role is at seeking preapproval for services with patient satisfaction-oriented duties.

• The Associate Pre-Approval is responsible for registration and length of stay (LOS) assignment for all acute care hospitals admissions.
• Reviews and discusses with nurses and physicians on denied cases or pending cases and get required justification from the treating doctor to resend it to Insurance Company and obtain the approval.
• Submits all requests, including required forms and limited documentation when requested, via DHPO/ websites.
• Notifies Hospitals by written notification of approval, rejection and denial of requests. Applies judgement in reconsideration for appeal of rejected cases.
• 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.
• Prepares reports of daily activity as requested for management and assists management in month end reporting as requested.

Primary Responsibilities

• Preapproval and Precertification for claims requiring approval.
• Monitoring and follow up on prior authorization for outpatient/inpatient services.
• 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 policys schedule of benefits.
• Scanning of cases to identify lack of documentation by physician/ reports prior to submitting to payer.
• Contacting the physician/nurses for further clarification to make the claim eligible for preapproval.
• Identify and analyze problems, take action to resolve, apply sound judgment and take responsibility for their resolution.
• Prepare cost estimate according to procedures for Cash Patient.
• Responsible for receiving, evaluating and escalating second opinion cases and case management.
• Respond to Insurance/ TPA queries adequately and liaise with concerned department without any delay.
• Inform and influence others by clear, concise expression of ideas and information in verbal and written as appropriate.
• 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.
• 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.
• Perform night shift duty and on public holidays as per duty roster.
• Reporting trends related to preapproval to reporting TL /Supervisor

Job Requirements

• Medical Background - Nursing /BAMS/BHMS/MBBS/BDS preferred.

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

Key Performance Indicators (KPI's)

• Completing the assigned/allocated preapproval claims as per TL/Supervisor >95% quality (error free) to be achieved on given tasks.
• Strict Adherence to process and protocols of payers and as well organization
• Maintain TAT for all approval within 24 to 48 hours