Job Description

Roles & Responsibilities

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

• valuate pre-approval requests for medical necessity based on submitted clinical documentation and accurately assign coding for requested services in accordance with accepted medical coding standards, medical guidelines, and policy benefits.

• Respond promptly to insurance companies and TPAs, and coordinate with relevant departments as required.

• Receive, assess, and escalate second-opinion cases and case management requests.

• Perform night shift duties and work on public holidays as per the approved duty roster.

• Prepare daily activity reports and support management with monthly reporting requirements.

• Coordinate and support internal and external auditing processes by arranging required documentation and liaising with coding staff.

• Attend meetings, presentations, and departmental discussions as required.

• Conduct training sessions for front office staff, receptionists, and nurses, ensuring they remain updated on insurance policies and procedures.

• Prepare cost estimates for procedures and services for cash-paying patients.

• Provide coverage and adjust duties during emergency or unplanned staff absences.

• Ensure smooth handover and management of pending cases to subsequent shifts.

• Perform additional duties assigned by the Head of Department within the scope of the role.

• Comply with all Occupational Safety and Health (OSH) and Infection Control policies, procedures, and standards.

• Follow documented OSH procedures and fulfill assigned safety responsibilities.

• Maintain awareness of emergency response and evacuation procedures.

• Report OSH hazards, incidents, near misses, and assist in risk assessments and incident investigations.

• Adhere to waste management policies and procedures.

• Participate in mandatory OSH, Infection Control training programs, mock drills, and awareness initiatives.

• Utilize appropriate personal protective equipment (PPE) and safety systems at all times.

Desired Candidate Profile

• Bachelor's Degree in Medicine (MBBS) from a recognized university.

• Minimum 2 years of experience in Insurance Claims Management and/or Adjudication.

• Strong knowledge and experience in medical coding systems, including ICD, CPT, DRG, and HCPCS.

• Excellent verbal and written communication skills in English.

• Flexible, adaptable, and able to work effectively under pressure in a fast-paced environment.

• Proficient in Microsoft Office applications, including Word, Excel, PowerPoint, and Outlook.