✨ AI Summary
The Approval Officer will review and verify Pre-Approval requests for insurance patients, applying medical knowledge and insurance practices to obtain necessary authorizations. This role involves ensuring requests comply with regulatory standards, handling rejections by liaising with treating doctors, and preparing daily and monthly activity reports. The position requires evaluating medical necessity, accurately coding service descriptions, and responding promptly to insurance queries. The Approval Officer will also escalate second-opinion cases and manage urgent operational needs, including covering for absent colleagues and handing over pending cases.
Key requirements include a Bachelor’s degree in Medicine or equivalent, a minimum of 2 years of experience in insurance claims management/adjudication, and familiarity with medical coding systems like ICD, CPT, DRG, and HCPCS. Excellent English communication skills, flexibility for shift work, and proficiency in Microsoft Office are also necessary. Experience with MBA/PG Diploma in Business Management (Finance) is preferred.
JOB SUMMARYApply medical knowledge and best insurance practices while reviewing and verifying Pre-Approval requests (OP/IP) received from different departments to obtain authorizations as required by insurance companies, depending on the plan coverage for all insurance patients.Ensure that Pre-Authorization Requests comply with regulatory standards, particularly claim adjudication rules and business rules.Handle rejected Pre-Authorization requests and obtain the required justification from the t
Requirements
Bachelor’s degree in Medicine or an equivalent medical degree from a recognized university.
Minimum 2 years of experience in insurance claims management/adjudication.
Knowledge of medical coding systems, including ICD, CPT, DRG, and HCPCS.
Excellent command of both written and spoken English.
Flexible and able to work under pressure and in shifts.
Proficiency in Microsoft Office applications
Description
JOB SUMMARYApply medical knowledge and best insurance practices while reviewing and verifying Pre-Approval requests (OP/IP) received from different departments to obtain authorizations as required by insurance companies, depending on the plan coverage for all insurance patients.Ensure that Pre-Authorization Requests comply with regulatory standards, particularly claim adjudication rules and business rules.Handle rejected Pre-Authorization requests and obtain the required justification from the treating doctor for resubmission to the insurance company and approval.Prepare daily activity reports as requested by management and assist with month-end reporting as required.DUTIES AND RESPONSIBILITIESEvaluate Pre-Approval requests for medical necessity based on the medical information provided.Accurately code service description codes stated on prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and the policy schedule of benefits.Respond to Insurance/TPA queries and liaise with concerned departments without delay.Receive, evaluate, and escalate second-opinion cases and case management requirements as appropriate.Prepare daily activity reports and assist with monthly reporting as required.Attend meetings and presentations as required.Adjust and manage duties in the event of sudden, emergency, or unplanned leave of colleagues to ensure continuity of operations.Manage and hand over pending cases, if any, to colleagues in the next shift.Perform any other duties or responsibilities assigned by the HOD from time to time within the scope of the job title.