Approval Officer

Role Overview

Approval Officer at NMC Healthcare. The role involves evaluating pre-approval requests, managing insurance authorizations, and ensuring compliance with medical coding standards and insurance guidelines.

Role Purpose

Apply medical knowledge and best insurance practice while reviewing and verifying pre-approval requests received from different departments to obtain authorizations as required by insurance companies dependent upon plan coverage for all insurance patients. Ensure that details of pre-authorization requests align with regulators' standards, especially claim adjudication rules and business rules.

Key Responsibilities

Pre-Authorization & Approval Management

• Evaluate pre-approval requests for medical necessity according to medical data provided.
• Accurately code service description codes stated on prior authorization requests according to accepted medical coding rules, medical guidelines, and policy schedule of benefits.
• Apply medical knowledge and best insurance practice while reviewing and verifying pre-approval requests (outpatient and inpatient) received from different departments.
• Handle rejected pre-authorization requests and obtain required justification from the treating doctor to resend to insurance company and obtain approval.

Insurance & Stakeholder Management

• Respond to insurance and TPA queries and liaise with concerned departments without delay.
• Train front office, receptionist, and nurses and keep them updated about insurance details.

Case Management

• Receive, evaluate, and escalate second opinion cases and case management.
• Manage and handle pending cases to next shift colleagues.

Audit & Compliance

• Handle auditing process.
• Arrange required documents and papers and check with coders to assist external auditors.

Reporting

• Prepare reports of daily activity as requested for management.
• Assist management in monthly and month-end reports as requested.

Operations & Support

• Perform night shift duty and on public holidays as per duty roster.
• Attend meetings and presentations.
• Prepare cost estimates for procedures for cash patients.
• Adjust duties in case of sudden or emergency unplanned leaves by colleagues.
• Perform any other jobs or duties assigned by the head of department from time to time within the scope of job title.

Qualifications & Experience

• Bachelor degree in medicine (MBBS) from a recognized university.
• Minimum 2 years experience in insurance claims management and adjudication.
• Experience in medical coding: ICD, CPT, DRG, and HCPCS.

Skills & Competencies

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