Outpatient (OP) Medical Board Executive
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About the Role
GIG Gulf seeks an Outpatient Medical Board Executive to assess and evaluate pre-approval requests for medical eligibility and policy terms. The role requires 3-5 years experience in medical insurance pre-approval, a medical/dental/nursing degree, and medical coding certification.
Key Skills for This Role
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Overview
Who we are
GIG Gulf (a Fairfax company) is part of the Gulf Insurance Group (GIG), the #1 largest regional composite insurer in the Middle East and North Africa, with presence in 12 markets including the United Arab Emirates, Bahrain, Oman, Qatar, Saudi Arabia, Algeria, Egypt, Iraq, Jordan, Kuwait, Lebanon, and Turkey.
GIG Group reported consolidated assets of US$ 3.83 billion and $69 million net profit for the year 2023.
The majority shareholder of GIG Group is Toronto based Fairfax Financial Holding, a global leader in insurance and reinsurance with a presence in 40 markets.
GIG Gulf is an ‘A’ rated regional insurer with a top 5 position in each of its markets (UAE, Oman, Qatar, Bahrain).
GIG Gulf has been present in the region for over 70 years with a strategic focus on both growth and investments and is a one stop shop offering a wide range of insurance products and services that cater to a broad variety of needs for corporates, SMEs and individual customers throughout UAE, Oman, Bahrain, and Qatar.
GIG Gulf also owns a 50% stake in GIG Saudi.
Our strategic objectives and guiding principles are focused on Regional Growth, Customer Experience and Digital Transformation.
GIG Gulf has created a diverse and inclusive working environment and culture with a workforce of over 800 employees, with over 60 nationalities, across 15 branches and retail shops region-wide and over 1 million customers.
GIG Gulf is a caring partner that encourages customers to achieve their goals and live an inspiring and fulfilling life.
We are obsessed with customer feedback and continuously evolving to become the region’s digital insurer of reference, committed to running our operations in a responsible, sustainable way
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Job Purpose
To assess and evaluate the preapproval requests received by the providers in terms of medical eligibility and policy terms and meeting the client expectations appropriately and providing a World Class Customer Service experience throughout the process.
Key Responsibilities
- Adjudicating and Processing insurance pre-approvals in a timely and accurate manner following Company policy terms and conditions, process Guidelines. Process pre-approvals within the agreed TAT per line of business.
- Providing preapproval for medical claims based on medical eligibility and policy terms.
- Contribution in cost containment through GIG Guidelines and proper medical adjudication.
- Contribution in Fraud Waste and Abuse management in the pre-approval function.
- Assist team leaders in Queue management, Customer care email management as required on adhoc basis.
Operational & Technical Responsibilities
- Sound knowledge of medical and insurance guidelines
- Ability to understand the different aspects of the Healthcare Platform to be able to direct queries to the relevant parties where necessary.
- Requires detailed understanding of the reasons for inclusion/exclusion of certain treatments or conditions.
- Sound knowledge of regulations from a regulatory authority.
- independent thought and judgment to evaluate medical decisions on an objective basis.
- Decide on pre-approval based on medical necessity and internationally accepted medical guidelines.
- Reporting of provider abuse if it is found to be recurrent as part of the cost-containment strategy of the health care operation.
- Individual quality monitoring, Identifying, and reporting opportunities for Quality improvement within the department.
- Able to validate the approval for the junior staffs.
- Case management within the scope of Outpatient approvals with enhanced Member experience and Savings.
Essential
- Minimum 3-5 years’ experience in Medical Insurance Pre-approval Process.
- Medical Coding Certification from AAPC/AHIMA
• Medical And Dental And Nursing Degree
- Flexibility to work in different shifts (24x7)
- Regional experience and working knowledge of healthcare regulations in UAE, Bahrain, Oman & Qatar.
Desirable
- Sound medical knowledge.
- Good analytical skills
- Experience in Outpatient Medical Coding and Billing
- Strong communication (verbal & written)
- Ability to work effectively within a team environment.
- Highly motivated and proactive
- Results-driven and solution-oriented
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