• JOB SUMMARY

  • Apply medical knowledge and best insurance practices while reviewing and verifying Pre-Approval requests (OP/IP) received from different departments to obtain authorizations as required by insurance companies, depending on the plan coverage for all insurance patients.

  • Ensure that Pre-Authorization Requests comply with regulatory standards, particularly claim adjudication rules and business rules.

  • Handle rejected Pre-Authorization requests and obtain the required justification from the treating doctor for resubmission to the insurance company and approval.

  • Prepare daily activity reports as requested by management and assist with month-end reporting as required.

    
    

  DUTIES AND RESPONSIBILITIES

  • Evaluate Pre-Approval requests for medical necessity based on the medical information provided.

  • Accurately code service description codes stated on prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and the policy schedule of benefits.

  • Respond to Insurance/TPA queries and liaise with concerned departments without delay.

  • Receive, evaluate, and escalate second-opinion cases and case management requirements as appropriate.

  • Prepare daily activity reports and assist with monthly reporting as required.

  • Attend meetings and presentations as required.

  • Adjust and manage duties in the event of sudden, emergency, or unplanned leave of colleagues to ensure continuity of operations.

  • Manage and hand over pending cases, if any, to colleagues in the next shift.

  • Perform any other duties or responsibilities assigned by the HOD from time to time within the scope of the job title.
    

Desired Candidate Profile

• Bachelor’s degree in Medicine or an equivalent medical degree from a recognized university.

• Minimum 2 years of experience in insurance claims management/adjudication.

• Knowledge of medical coding systems, including ICD, CPT, DRG, and HCPCS.

• Excellent command of both written and spoken English.

• Flexible and able to work under pressure and in shifts.

• Proficiency in Microsoft Office applications