Description

Job Description

Job Description

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.

Responsibilities

• Evaluate pre-approval requests for medical necessity based on the provided medical data and accurately code the service description according to accepted medical coding rules, medical guidelines, and policy schedule of benefits.
• Respond to Insurance/TPA queries and coordinate with the concerned departments without delay.
• Receive, evaluate, and escalate second-opinion cases and case management as required.
• Perform night shift duties and work on public holidays as per the duty roster.
• Prepare daily activity reports as requested by management and assist in monthly reports when needed.
• Handle the auditing process, arrange required documents, and coordinate with coders to support external auditors.
• Attend meetings and presentations.
• Train Front Office, Receptionists, and Nurses, ensuring they remain updated on insurance details.
• Prepare cost estimates for procedures for cash patients.
• Adjust duties in cases of sudden or emergency unplanned leaves by colleagues.
• Manage and hand over any pending cases to the next shift colleagues.
• Perform any other tasks assigned by the HOD within the scope of the job title.
• Comply with all OSH and infection control policies, standards, and procedures, and cooperate with hospital management to meet these requirements.
• Work in accordance with documented OSH procedures, instructions, and specific responsibilities.
• Be familiar with emergency and evacuation procedures.
• Report OSH hazards, incidents, near misses, and issues, and assist with risk assessments and incident reports.
• Comply with waste management procedures and policies.
• Attend applicable OSH/Infection Control training programs, mock drills, and awareness programs.
• Use appropriate personal protective equipment and safety systems.

Qualifications

• Bachelor’s Degree in Medicine (MBBS) from a recognized university.
• Minimum 2 years of experience in insurance claims management/adjudication.
• Experience in medical coding including ICD, CPT, DRG, and HCPCS.
• Excellent command of oral and written English.
• Flexible and able to work under pressure.
• Excellent knowledge of Microsoft applications.