Role Purpose

As a Pre-Approval Officer, you will play a vital role in the Healthcare RCM Approval Unit, ensuring timely and accurate submission of insurance pre-approvals for inpatient, outpatient, and pharmacy services. You will collaborate with physicians, coding teams, and insurance companies to optimize approval rates, prevent revenue loss, and uphold compliance with DHA and payer regulations.

Key Responsibilities

• Review and process all assigned claim forms, ensuring completeness and accuracy.
• Update approvals received from insurance companies with 100% accuracy.
• Communicate with departments to obtain missing documents or additional information.
• Meet daily claims verification productivity targets.
• Perform comprehensive quantitative and qualitative analysis of medical records.
• Ensure compliance with coding guidelines, legal, and regulatory requirements.
• Submit all pre-approvals in line with KPIs and improve first-round approval rates.
• Monitor and coordinate with stakeholders to prevent revenue loss and address insurance rejections.
• Analyze denial trends and implement corrective actions.
• Maintain accurate records and escalate denied approvals as needed.
• Educate and coordinate with billing, approval, and clinical documentation teams to enhance process flow and compliance.

Skills

Qualifications, Experience & Skills

• Certified professional coding certificate from a reputed institution.
• Certified medical/paramedical qualification.
• Minimum 3+ years’ experience in a similar role.
• Strong medical background for efficient reconciliation.
• Excellent negotiation, presentation, and analytical skills.
• Strong operational thinking and decision-making abilities.
• Ability to work under pressure and achieve targets.
• Excellent communication and stakeholder management skills.