Claims Officer (Pre-Authorization) - Insurance TPA

1. JOB PURPOSE

2. RESPONSIBILITIES AND DUTIES

• Part of a clinical team that provides medical management services to customers worldwide but mainly in Middle East and Africa region.
• Give evidence-based advice on pre-authorization, considering internationally accepted protocols and local and/or regional customs and regulations.
• Assessing pre-authorization requests claims in line with the policy coverage and medical necessity.
• Identify and refer cases to the Cigna Clinical Programs team for case management, disease management and other clinical services.
• Assist is the coordination of processes for improving quality of care and health outcomes for specifically delineated projects or populations.
• Assist and support the team in cost containment, assist in projects and service delivery to meet goals.
• To assist queries from providers and payers via phone calls or e-mails
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• Might be required to assist in training colleagues and sharing knowledge.
• Ability to review, investigate, and respond to external and internal inquires/complaints and provide guidance to other clinical and non-clinical staff related to medical necessity.
• Assist in fraud detection
• Meeting the defined qualitative and quantitative key performance metrics for the assigned job role.
• Ensure adherence to the predefined TATs for pre-approvals
• Achieving required targets assigned by the team leader on daily, weekly, and monthly basis.
• Ensure compliance to any changes in terms of system parameters or process.
• Other duties as assigned

3. KNOWLEDGE, SKILLS AND EXPERIENCE

• University degree of Medical /Para-medical specialization with international healthcare experience.
• 2-3 years of clinical experience preferable in a payer setting on medical management.
• Strong interpersonal and communication skills.
• Ability to operate a personal computer, proficient with Microsoft office products, call centre software and a variety of software for medical management.
• Knowledge of utilization/case management, cost containment services, managed care, insurance coverage, and financial management a plus.
• Ability to build solid working relationships with staff, matrix partners, clients, customers, and healthcare providers.
• Demonstrates pro-active problem-solving and analytical skills
• Stress resistant and efficient, finding a good balance between quality and quantity
• Ability to speak, write and read English, any other language a plus
• Flexible to work on shifts/team schedule
• Pay: AED7,000.00 per month

Application Question(S)

• Willing to work in flexible shifts/team schedule?

Experience

• Medical insurance: 2 years (Required)