Approval Officer

Role Overview

Approval Officer at NMC Healthcare. The role involves reviewing and verifying pre-approval requests for insurance authorization across outpatient and inpatient departments.

Role Purpose

Apply medical knowledge and insurance best practice to review and verify pre-approval requests from departments, obtain insurance authorizations based on plan coverage and regulator standards, and ensure compliance with claim adjudication and business rules.

Key Responsibilities

Pre-Approval Review and Authorization

• Evaluate pre-approval requests for medical necessity based on clinical information provided.
• Review and verify pre-approval requests (OP/IP) received from different departments to obtain authorizations as required by insurance companies.
• Ensure details of pre-authorization requests align with regulator standards, especially claim adjudication rules and business rules.
• Accurately code service descriptions stated in prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and policy schedule of benefits.

Claims and Query Management

• Handle rejected pre-authorization requests and obtain required justification from treating doctors to resend to insurance companies and obtain approval.
• Respond promptly to insurance and TPA queries and coordinate with concerned departments for timely resolution.
• Receive, evaluate, and escalate second-opinion cases and case management matters as required.
• Prepare cost estimates for procedures for cash-paying patients.

Reporting and Documentation

• Prepare reports of daily activity as requested by management.
• Assist management in month-end reporting as requested.
• Prepare daily activity reports as required by management and assist with preparation of monthly reports.

Training and Staff Support

• Conduct training sessions for Front Office, Reception, and Nursing staff and keep them updated on insurance-related requirements and processes.
• Adjust and manage duties in the event of sudden or emergency unplanned leave of colleagues.
• Manage and hand over pending cases to colleagues in the next shift to ensure continuity of work.

Audit and Compliance Support

• Handle the auditing process by arranging required documents and coordinating with coders to support external auditors.
• Comply with all Occupational Safety and Health (OSH) and infection control policies, standards, and procedures.
• Follow documented OSH procedures, instructions, and assigned responsibilities.
• Report OSH hazards, incidents, near misses, and other safety-related issues promptly.
• Assist with preparation of risk assessments and incident reports.
• Comply with waste management policies and procedures.
• Ensure appropriate use of personal protective equipment (PPE) and safety systems.

General Operations

• Perform night shifts and public holiday duties as per the approved duty roster.
• Attend meetings and presentations as required.
• Maintain familiarity with emergency and evacuation procedures.
• Attend applicable OSH and infection control training programs, mock drills, and awareness programs.
• Perform any other duties assigned by the Head of Department within the scope of the job role.

Qualifications & Experience

• Bachelor's Degree in Medicine (MBBS) from a recognized university.
• Minimum 2 years of experience in Insurance Claims Management or Adjudication.
• Proficiency in Medical Coding, including ICD, CPT, DRG, and HCPCS.

Skills & Competencies

• Excellent command of spoken and written English.
• Excellent knowledge of Microsoft Office applications.
• Flexible and able to work effectively under pressure.

Additional Information

• Night shifts and public holiday duties required as per approved duty roster.