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.
Handling the rejected pre authorization and get required justification from the treating doctor to resend it to Insurance Company and obtain the approval.
Prepares reports of daily activity as requested for management and assists management in month end reporting as requested.
- Evaluate pre-approval requests for medical necessity based on provided medical data and accurately code service description codes on prior authorization requests, in line with medical coding rules, guidelines, and policy’s schedule of benefits
- Respond to Insurance/TPA queries and liaise promptly with the concerned department
- Receive, evaluate, and escalate second opinion cases and case management requests
- Perform night shift duties and work on public holidays as per duty roster
- Prepare daily activity reports as requested by management and assist in compiling monthly reports
- Handle auditing processes: arrange required documents, coordinate with coders, and support external auditors
- Attend meetings and presentations as required
- Train front office staff, receptionists, and nurses, ensuring they are updated about insurance details
- Prepare cost estimates for procedures for cash patients
- Adjust duties to cover sudden/emergency unplanned leaves of colleagues
- Manage and hand over pending cases (if any) to colleagues in the next shift
- Perform any other duties assigned by the HOD within the scope of the job title
- Bachelor’s Degree in Medicine (MBBS) from a recognized university
- Minimum 2 years of experience in insurance claims management/adjudication
- Hands-on experience in Medical Coding : ICD, CPT, DRG, and HCPCS
- Excellent command of oral and written English
- Flexible and able to work effectively under pressure
- Strong knowledge of Microsoft applications
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