Job Description

Job summary:

The Pre-Authorization Medical Officer is responsible of reviewing the authorization requests that were flagged by the system for manual review, and taking appropriate decisions based on policy coverage and medical guidelines; to accept / reject the approval request or enquire further information or documents from the provider or member, and to assure the best case management in the way that guarantees the customer safety with the least liabilities.

Duties & Responsibilities:

• Review all kinds of preauthorization requests in accordance with medical guidelines, policy benefits and coverage terms
• Adjudicate all requested services, with sound and consistent medical decisions, in a timely manner.
• Determine whether the service is medically necessary and appropriate and ensure the decisions are being made according to policy coverage and terms, contract terms and conditions, best medical standards, and cost effectiveness
• Pay meticulous attention regarding declaration, special notes, and financial limitation
• Validate and ensure appropriateness and accuracy of ICD coding, approved quantities, approved mounts, and Length of stay.
• Identify and report medical abuse, overtreatment, and suspected fraud in all forms and report such behavior according to guidelines.
• Handle Referral requests and ensure medical necessity, appropriateness, and cost effectiveness according to referral matrix.
• Discuss the high value cases and/or critical cases with the providers’ treating physicians and escalate it to direct supervisor or manager as well as roving doctor when required.
• Attend and evaluate complaints and submit detailed response based on facts and solid medical and scientific background.
• Take active part in all activities related to smooth running of the daily work of the team including system upgrade, testing, automation programs, manuals / process enhancement, and reporting activity.               
• Maintain full cooperation with colleagues in Account relation, Customer care departments by providing them with all the support needed to handle calls and solve complaints arising as a result of preauthorization process.
• Follows policies and procedures; Completes administrative tasks correctly and on time. Supports organization’s goals and values. Gives and welcomes feedback, while contributing to build a positive team spirit.

• To respect and comply with all cybersecurity practices adopted by the company and mentioned in the Cybersecurity end user manual.

Skills/Qualifications:

BSC in medicine & surgery

Minimum 3 years of clinical experience at reputable and recognized hospitals and health institutions.

Previous experience in similar position (Approval / claims – preferably 2 years).

Decision making and Problem-solving skills.

Active listening and Excellent communication skills.

Team work skills.

Ethical, integral, professional, and Punctual.

Intermediate skills in Microsoft excel and Word.

Initiative, persuasive, flexible, and supportive.

Fluent spoken and written English and Arabic languages.