Job Description

Job Category: Administration
:
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 and accurately code service descriptions per medical coding rules, guidelines, and policy schedule of benefits.
Respond to Insurance/TPA queries and liaise with relevant departments promptly.
Receive, evaluate, and escalate second opinion cases and case management.
Perform night shift duties and work on public holidays as per duty roster.
Prepare daily activity reports for management and assist in monthly reporting.
Handle auditing processes: arrange required documents, coordinate with coders, and assist external auditors.
Attend meetings and presentations.
Train front office, reception, and nursing staff on insurance updates.
Prepare cost estimates for procedures for cash patients.
Adjust duties in case of sudden or emergency unplanned leaves by colleagues.
Manage and hand over pending cases to the next shift colleagues.
Perform any other duties assigned by the HOD within the scope of the job.
Comply with all OSH and infection control policies, standards, and procedures.
Follow documented OSH procedures and specific responsibilities.
Be familiar with emergency and evacuation procedures.
Report OSH hazards, incidents, near misses, and assist in preparing risk assessments and incident reports.
Comply with waste management procedures and policies.
Attend OSH/infection control training, mock drills, and awareness programs.
Use appropriate personal protective equipment (PPE) 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: ICD, CPT, DRG, and HCPCS.
Excellent command of written and spoken English.
Flexible and able to work under pressure.
Strong knowledge of Microsoft applications.

Skills Required