Executive, Preauthorization
Skills
About This Role
Job Purpose
- The job holder will be responsible for medical audit, PAR administration, control of fraud / abuse and assurance of customer service.
- Receive intimation from Provider through over regulatory portal/e-mail (non-network providers) along with relevant medical reports.
Key Accountabilities
- Coordinate with providers for case management and cost control.
- Ensure appropriate handling of the customer queries and concerns and achieving FTR.
- Ensure adherence to agreed SLAs for OP/IP Adjudications.
- Address client/broker and provider queries.
- Escalate customer issues and concerns where the timely resolution is not being achieved in light of the laid out policy and turn around time.
- Assist in the running of the PAR unit on a daily 24/7 basis.
- Ensure adherence to unit KPIs and internal and external SLAs.
- Assist in implementation of medical pre-approval processes and regulatory guidelines.
- Conduct onsite visits for audit of suspected cases of fraudulent practice by providers and highlight to FWA and Network team.
- Review and audit medical approvals and conclude pending approvals.
- Ensure implementation and maintenance of relevant management information systems, quality controls and SOPs.
Qualifications
- Medical degree or relevant clinical qualification with strong exposure to health insurance operations.a
- Proven experience in medical auditing, pre-authorization (PAR), claims adjudication, and fraud/waste/abuse (FWA) control.
- Solid understanding of healthcare systems, insurance policies, and regulatory requirements.
- Strong decision-making ability with demonstrated capability to assess and authorize eligible medical cases.
- Excellent communication skills in English (written and verbal); Arabic language skills are an advantage.
- Proficient in IT systems, including MS Office Suite, healthcare claims management systems, and MIS reporting tools.
- Knowledge of medical coding standards (e.g., ICD, CPT) is highly desirable.
- Experience in business process improvement, including process mapping, workflow documentation, and optimization initiatives.
- Familiarity with quality improvement methodologies such as Lean, Six Sigma, or similar frameworks.
- Ability to manage multiple priorities in a 24/7 operational environment while ensuring adherence to SLAs, KPIs, and regulatory guidelines.
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