Approval Officer

Role Overview

Approval Officer at NMC Healthcare. The role is based at NMC Healthcare locations.

Role Purpose

Apply medical knowledge and best insurance practices to review and verify Pre-Approval requests (OP/IP) received from different departments, obtain authorizations as required by insurance companies based on plan coverage for all insurance patients, and ensure compliance with regulatory standards, particularly claim adjudication rules and business rules.

Key Responsibilities

Pre-Authorization Review and Approval

• Evaluate 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.
• Ensure that Pre-Authorization Request details comply with regulatory standards, particularly claim adjudication rules and business rules.

Insurance and Claims Management

• Handle rejected Pre-Authorization requests and obtain required justification from the treating doctor for resubmission to the insurance company and approval.
• 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.

Reporting and Administration

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

Operations and Coverage

• 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 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.

Qualifications & Experience

• Bachelor's degree in Medicine or an equivalent medical degree from a recognized university.
• Minimum 2 years of experience in insurance claims management or adjudication.
• Knowledge of medical coding systems, including ICD, CPT, DRG, and HCPCS.

Skills & Competencies

• Excellent command of both written and spoken English.
• Proficiency in Microsoft Office applications.
• Ability to work under pressure and in shifts.
• Flexible and adaptable to changing workloads and schedules.

Additional Information

• Flexible shift work required.