Requirements
Requires an MBBS/MD or equivalent medical degree with 3-7 years of clinical practice and/or health insurance claims management experience. Experience in preauthorization, utilization management, medical claims review, or managed care is preferred. Must have knowledge of medical terminology, disease conditions, treatment protocols, ICD-10, CPT, HCPCS, and DRG coding systems, as well as familiarity with health insurance regulations and healthcare reimbursement processes. Strong analytical, communication, and decision-making skills are essential, particularly for physicians with experience in the UAE health insurance claims process and knowledge of DOH, DHA, and MOHAP regulations.
Description
The Health Authorization Specialist is responsible for reviewing, processing, and adjudicating health claim requests received from TPAs in accordance with policy coverage, clinical guidelines, regulatory requirements, and service-level agreements. The role ensures that medically necessary services are appropriately authorised while maintaining member satisfaction, cost management, and compliance standards.ResponsibilitiesReceive and review authorization requests submitted by TPA's.Verify member eligibility, benefits, policy coverage, and authorization requirements.Evaluate requests against policies, clinical guidelines, medical necessity criteria, and contractual agreements.Coordinate with Medical Directors, clinicians, and case management teams for clinical reviews when required.Approve, modify, or deny authorization requests in accordance with established guidelines.Communicate authorization decisions to TPA's and stakeholders within defined turnaround times.Request and review additional medical records or supporting documentation when necessary.Maintain accurate records of authorization decisions and supporting rationale in the claims/authorization system.Ensure compliance with regulatory requirements, accreditation standards, and company policies.Support appeals and reconsideration processes by providing authorization documentation and case history.Monitor authorization queues and ensure adherence to operational SLAs.Identify trends in authorization requests, denials, and provider inquiries for process improvement initiatives.Collaborate with Claims, Provider Relations, Utilization Management, Case Management, and Customer Service teams.QualificationsMBBS / MD or equivalent medical degree recognized by the relevant health authority.3–7 years of clinical practice and/or health insurance claims management experience.Experience in preauthorization, utilization management, medical claims review, or managed care preferred.Knowledge of medical terminology, disease conditions, and treatment protocols.Familiarity with ICD-10, CPT, HCPCS, and DRG coding systems.Strong analytical, communication, and decision-making skills.Familiarity with health insurance regulations and healthcare reimbursement processes.A physician with strong experience in the UAE health insurance claims process, possessing a comprehensive understanding of DOH, DHA, and MOHAP regulations.