Approval Officer

Overview

• 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.
• 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.
• 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.