Requirements
Bachelor's degree in medicine, pharmacy, or related healthcare field is required. Certification in healthcare management or insurance is a plus. 2-5 years of experience in medical pre-authorization, claims processing, or case management within a health insurance or healthcare provider environment is necessary. Familiarity with health insurance industry practices, policies, and regulations is essential. Proficiency in medical terminology, diagnostics, clinical procedures, and treatment protocols, along with knowledge of ICD and CPT coding systems, is mandatory. Excellent verbal and written communication skills in Arabic and English are required. Proficiency in NPHIES, CRM and other healthcare IT systems, and MS Office is also a must. Strong analytical, decision-making, customer focus, time management, teamwork, and problem-solving skills are expected.
Description
The Medical Pre-Authorization Officer is responsible for evaluating and processing pre-authorization requests for medical services, ensuring compliance with company policies, insurance guidelines, and medical necessity criteria to facilitate efficient service delivery for policyholders. The officer will also handle case management for in-patient admissions to ensure efficient use of resources while maintaining high-quality patient care.Key Responsibilities: Medical Pre-Authorization:Verify eligibility and coverage of the insured members.Evaluate requests for medical services, diagnostics, treatments, procedures, and hospital admissions to determine coverage eligibility and compliance with policy terms.Approve or deny requests based on medical necessity, policy limits, and established guidelines.Assess pre-existing conditions and undeclared medical history in alignment with CCHI Unified Policy and CHI Implementing Regulations, and apply appropriate coverage exclusions where applicable.Promptly and professionally communicate authorization decisions to healthcare providers and policyholders.Ensure adherence to turnaround time (TAT) requirements for all pre-authorization requests.Monitor utilization rates and identify early signs of fraud, waste, abuse (FWA), or suspicious patterns, including anti-selection behaviors, with the ability to report findings.Case ManagementMonitor inpatient admissions to ensure appropriate utilization of medical services and compliance with insurance policy terms.Liaise with healthcare providers, patients, and internal teams to coordinate care plans.Arrange for a Second Medical Opinion in selected cases at one of the trusted Consultants.Arrange for Roving doctor's visit for on-site assessment and review of cases with certain agreed flags.Review discharge plans and post-discharge needs for coverage considerations.Data HandlingAccurately document all pre-authorization and case management decisions in the company's system.Maintain confidentiality of medical and insurance records in accordance with company policy and legal regulations.Business CorrespondenceManage queries from providers, Insurance Companies and insured members relating to medical approvals. Provide medical guidance to the Claims Department staff and resolve inquiries related to all pre-authorization decisions and justification.Assist in resolving escalated issues related to pre-authorization from Customer Care.ReportingGenerate regular reports on pre-authorization activities, approvals, and denials for internal review.Compliance and CommunicationStay updated on medical coding (ICD, CPT), medical advancements, CCHI Unified Policy, CHI Implementing Regulations, and relevant Insurance Authority (IA) circulars and guidelines.Maintain confidentiality and comply with all health insurance industry standards, including HIPAA or equivalent regional guidelines. Performance MonitoringMeet or exceed key performance indicators (KPIs) such as: turnaround time (TAT), authorization accuracy rate, pre-existing condition detection rate, rejection justification quality, and escalation handling efficiency.Contribute to achieving Cost Efficiency expectations.Redirect cases to cost-effective appointed providers and apply the Second Medical Opinion (SMO) framework where clinically and financially appropriate, in alignment with the departmental cost containment policy.Customer Service:Respond to the inbound phone calls referred to and generate outbound calls whenever needed to ensure optimal customer satisfaction.Respond to all related clients inquiries through email, etc. Identify and manage complaints from customers, insured groups, and payers and report them to the stakeholders.Education:Bachelor's degree in medicine, pharmacy or related healthcare field.Certification in healthcare management or insurance is a plus.Experience:2–5 years of experience in medical pre-authorization, claims processing, or case management within a health insurance or healthcare provider environment.Familiarity with health insurance industry practices, policies, and regulations.Personal Attributes / Skills:Medical Knowledge:Proficiency in understanding medical terminology, diagnostics, clinical procedures, and treatment protocols.Familiarity with health insurance processes, including pre-authorization workflows and coverage guidelines.Knowledge of ICD and CPT coding systems. Analytical and Decision-Making Skills:Ability to assess medical requests critically and make sound authorization decisions based on guidelines.Strong attention to detail for accurate documentation and reporting.Communication Skills:Excellent verbal and written communication skills to interact with healthcare providers, patients, and internal teams.Multilingual proficiency: Arabic and English are mandatory given the nature of provider and member communication in KSA. Technical Skills:Proficiency in using NPHIES (National Platform for Health Information Exchange Systems) — mandatory. Proficiency in CRM and other healthcare IT systems is required.Advanced skills in MS Office (Word, Excel, and PowerPoint) for reporting and documentation.Customer Focus:A patient-centric approach to handling pre-authorization and case management tasks.Ability to manage challenging situations professionally and empathetically.Time Management:Proven ability to handle high volumes of requests efficiently without compromising quality or compliance.Meet deadlines for all assigned tasks.Teamwork:Collaborate effectively with internal and external stakeholders.Problem-Solving: Quickly resolves pre-authorization issues with professionalism and accuracy.