Approval Officer

Role Overview

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

Role Purpose

Apply medical knowledge and insurance best practice to review, verify, and authorize pre-approval requests from different departments in line with insurance company requirements, regulator standards, and claim adjudication rules.

Key Responsibilities

Pre-Authorization & Claims Management

• Review and verify pre-approval requests (outpatient and inpatient) received from different departments to obtain insurance authorizations based on plan coverage.
• Ensure pre-authorization request details align with regulator standards, claim adjudication rules, and business rules.
• Evaluate pre-approval requests for medical necessity based on clinical information provided.
• Handle rejected pre-authorizations by obtaining required justification from treating doctors and resubmitting to insurance companies for 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.

Medical Coding & Documentation

• Accurately code service descriptions in prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and policy schedules of benefits.
• Support the auditing process by arranging required documents and coordinating with coders to support external auditors.

Reporting & Analysis

• Prepare daily activity reports as requested by management.
• Assist management with month-end reporting as required.

Stakeholder Management & Training

• Conduct training for front office, reception, and nursing staff on insurance-related requirements and processes.
• Keep staff updated on insurance-related requirements and processes.

Operations & Cost Management

• Prepare cost estimates for procedures for cash-paying patients.
• Manage pending cases and ensure proper handover to colleagues in the next shift.
• Adjust and manage duties in the event of sudden or emergency unplanned leave of colleagues.
• Perform night shifts and public holiday duties as per the approved duty roster.
• Attend meetings and presentations as required.
• Perform any other duties assigned by the head of department within the scope of the job role.

Occupational Safety & Health

• Comply with all occupational safety and health (OSH) and infection control policies, standards, and procedures.
• Follow documented OSH procedures, instructions, and assigned responsibilities.
• Maintain familiarity with emergency and evacuation procedures.
• Promptly report OSH hazards, incidents, near misses, and other safety-related issues.
• Assist with the preparation of risk assessments and incident reports.
• Comply with waste management policies and procedures.
• Attend applicable OSH and infection control training programs, mock drills, and awareness programs.
• Ensure appropriate use of personal protective equipment (PPE) and safety systems.

Qualifications & Experience

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

Skills & Competencies

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