Job Description

Job Category: Administration
:
2.1 Apply medical knowledge and best insurance practice while reviewing and verifying the Pre-Approval requests (OP) 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 Handing other responsibilities assigned by HOD.
2.4 Supervise and manage the authorization team.
Responsibilities:

• Managing the authorization team
• Assigning staff duty roasted in coordination with HOD
• 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
• Respond to Insurance/ TPA queries and liaise with concerned department without any delay.
• Responsible for receiving, evaluating and escalating second opinion cases and case management
• Perform night shift duty and on public holidays as per duty roster.
• Prepares reports of daily activity as requested for management and assists management in monthly reports as requested.
• Handle Auditing Process, arrange required documents and papers and check with coders in order to assist the external Auditors
• Attend Meetings and Presentation
• Train Front office, Receptionist and Nurses and keep them updated about Insurance details.
• To adjust duties in case of any sudden/ emergency unplanned leaves by colleagues.
• Managing and handling pending cases (if any) to the next shift colleagues.
• Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.
• Comply with all OSH and infection control policies, standards and procedures and cooperate with hospital management to comply those requirements.
• Work accordance with the documented OSH procedures and instructions, specific responsibilities
• Be familiar with emergency and evacuation procedures
• Notifying OSH Hazards, incidents, Near misses and issues and assistance with the preparation of risk assessments, incident reports
• Comply with Waste management procedures and policies
• Attend applicable OSH/Infection control training programs, mock drills and awareness programs
• Use of appropriate personal protective equipment and safety systems
• Ensure that employee follow applicable OSH/ Infection control policies, procedures and standards
• Provide OSH information, training and Supervision to the staff
• Report any OSH relevant Incident, Near misses and hazards in the departments in timely manner
• Make sure that incident corrective action has been implemented
• Assist with preparation of risk assessments and monitoring the control measures
• Ensure trainings are conducted, including general/departmental/FMS/OSH orientation for new employees and transferred employees, refresher training for department staff

Qualifications:
Bachelor's degree or graduate from a recognized university
Minimum 5 years of experience in Insurance Claims Management/Adjudication
Experience in Medical Coding (ICD, CPT, DRG, and HCPCS)
Excellent command of oral and written English
Flexible and able to work under pressure
Excellent knowledge of Microsoft applications
Experience in managing a team

Skills Required