Evaluate pre-approval requests for medical necessity based on the clinical information provided.
Accurately code service descriptions stated in prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and the policy schedule of benefits.
Respond promptly to Insurance/TPA queries and coordinate with the concerned departments for timely resolution.
Receive, evaluate, and escalate second-opinion cases and case management matters as required.
Perform night shifts and public holiday duties as per the approved duty roster.
Prepare daily activity reports as required by management and assist with the preparation of monthly reports.
Handle the auditing process by arranging required documents and coordinating with coders to support external auditors.
Attend meetings and presentations as required.
Conduct training sessions for Front Office, Reception, and Nursing staff and keep them updated on insurance-related requirements and processes.
Prepare cost estimates for procedures for cash-paying patients.
Adjust and manage duties in the event of sudden or emergency unplanned leave of colleagues.
Manage and hand over pending cases to colleagues in the next shift to ensure continuity of work.
Perform any other duties assigned by the HOD within the scope of the job role.
Comply with all OSH and infection control policies, standards, and procedures.
Follow documented OSH procedures, instructions, and assigned responsibilities.
Maintain familiarity with emergency and evacuation procedures.
Report OSH hazards, incidents, near misses, and other safety-related issues promptly.
Assist with the preparation of risk assessments and incident reports.
Comply with waste management policies and procedures.
Attend applicable OSH and infection control training programs, mock drills, and awareness programs.
Ensure appropriate use of personal protective equipment (PPE) and safety systems.
Desired Candidate Profile
Bachelor’s Degree in Medicine (MBBS) from a recognized university.
Minimum 2 years of experience in Insurance Claims Management/Adjudication.
Proficiency in Medical Coding, including ICD, CPT, DRG, and HCPCS.
Excellent command of spoken and written English.
Flexible and able to work effectively under pressure.
Excellent knowledge of Microsoft Office applications.