Approval Officer

Role Overview

Approval Officer at NMC Healthcare, managing pre-authorization request handling and claims adjudication to ensure timely patient care authorization and compliance with insurance and regulatory requirements.

Role Purpose

Manage the full pre-authorization lifecycle by verifying insurance eligibility, obtaining payer approvals, resolving rejected requests, and ensuring all authorization activities align with regulatory standards and business rules.

Key Responsibilities

Pre-Authorization & Approval Management

• Handle rejected pre-authorizations by obtaining required justification from treating doctors and resending to the Insurance Company.
• Complete service and procedure authorizations and referrals.
• Obtain approval once all necessary information is gathered.
• Verify customers' insurance eligibility and authorization in a timely and accurate manner.

Compliance & Standards

• Ensure that details of Pre-Authorization Requests are in line with regulators' standards, especially claim adjudication rules and business rules.
• Guide doctors and concerned staff to follow correct ICD, CDT, and CPT codes to avoid rejection.

Communication & Coordination

• Communicate payer authorization and eligibility information to relevant stakeholders.
• Send payer informational correspondence.
• Contact referral physicians for additional information when necessary.
• Notify concerned staff and treating physicians once approval is obtained.
• Notify branch management of concerns with payer coverage or other service noncoverage.

Patient & Data Management

• Review patient medical history and insurance coverage for approval.
• Enter new patient information and update data in the system.
• Assist with other clerical responsibilities as needed.

Monitoring & Reporting

• Keep track of daily production reports.
• Keep the pending approval monitoring system updated for next-day follow-up.
• Monitor schedules, emergency requirements, and facility queries in coordination with supervisor and team leader.

Qualifications & Experience

• College Diploma in any discipline or related field.
• 2+ years of experience in insurance claims management or pre-authorization (approval) processes.

Skills & Competencies

• Proficiency in medical coding standards: ICD, CPT, DRG, and HCPCS.
• Knowledge of CDT coding standards.