Job Description
Job Description
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
3.1 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
3.2 Respond to Insurance/ TPA queries and liaise with concerned department without any delay.
3.3 Responsible for receiving, evaluating and escalating second opinion cases and case management
3.4 Perform night shift duty and on public holidays as per duty roster.
3.5 Prepares reports of daily activity as requested for management and assists management in monthly reports as requested.
3.6 Handle Auditing Process. Arrange required documents and papers and check with coders in order to assist the external Auditors
3.7 Attend Meetings and Presentation
3.8 Train Front office, Receptionist and Nurses and keep them updated about Insurance details.
3.9 Prepare cost estimate for procedures for Cash Patient
3.10 To adjust duties in case of any sudden/ emergency unplanned leaves by colleagues.
3.11 Managing and handling pending cases (if any) to the next shift colleagues.
3.12 Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.
Responsibilities
- Apply medical knowledge and best insurance practices to review and verify Pre-Approval requests (OP/IP) from various departments to obtain authorizations based on insurance plan coverage. Ensure requests comply with regulators’ standards, including claim adjudication and business rules.
- Handle rejected pre-authorizations by obtaining necessary justification from the treating doctor and resubmitting to the insurance company for approval.
- Prepare daily activity reports as requested and assist management with month-end reporting.
Duties and Responsibilities:
- Evaluate Pre-Approval requests for medical necessity and accurately code service description codes according to accepted medical coding rules, guidelines, and policy schedules.
- Respond promptly to insurance/TPA queries and liaise with relevant departments.
- Receive, evaluate, and escalate second opinion cases and case management issues.
- Perform night shift duties and work on public holidays as per duty roster.
- Assist management with daily and monthly reporting activities.
- Handle auditing processes by arranging required documents and coordinating with coders to support external auditors.
- Attend meetings and presentations.
- Train front office staff, receptionists, and nurses, keeping them updated on insurance procedures and policies.
- Prepare cost estimates for procedures for cash patients.
- Adjust duties in case of sudden or emergency leaves by colleagues.
- Manage and hand over pending cases to next shift colleagues.
- Perform any other duties assigned by the HOD within the scope of the job title.
Qualifications
Strong knowledge of Microsoft applications.
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 spoken and written English.
Flexible and able to work effectively under pressure.
