Medical Approval Officer
3 weeks ago
Key Responsibilities
Medical Pre-Authorization:
- Verify the eligibility and coverage of insured members.
- Assess requests for medical services, treatments, and hospital admissions for compliance with policy terms.
- Approve or deny requests based on medical necessity, policy limits, and guidelines.
- Communicate authorization decisions to providers and policyholders promptly.
- Monitor utilization trends and identify potential fraud, waste, or abuse.
Case Management:
- Oversee inpatient admissions to ensure appropriate utilization of services.
- Coordinate care plans with providers, patients, and internal teams.
- Arrange second medical opinions and roving doctor visits for flagged cases.
- Review discharge plans and post-discharge needs for coverage considerations.
Data Handling:
- Accurately document decisions in the company's system.
- Ensure confidentiality of medical and insurance records.
Business Correspondence:
- Address queries from providers, insurers, and insured members.
- Provide medical guidance to claims staff and resolve pre-authorization inquiries.
- Assist in resolving escalated issues from Customer Care.
Reporting:
- Generate reports on pre-authorization activities, approvals, and denials.
Compliance and Communication:
- Stay updated on ICD, CPT coding, medical advancements, and regulatory requirements.
- Ensure compliance with health insurance standards and regulations.
Performance Monitoring:
- Meet key performance indicators (KPIs) for turnaround times and service quality.
- Contribute to cost efficiency and utilization management goals.
Customer Service:
- Respond to inquiries via phone, email, and other channels.
- Manage complaints and escalate unresolved issues to stakeholders.
Qualifications & Experience
Education:
- Bachelor's degree in Medicine, Pharmacy, or a related healthcare field.
- Certification in healthcare management or insurance is a plus.
Experience:
- 2–5 years of experience in medical pre-authorization, claims processing, or case management.
- Familiarity with health insurance practices and regulations.
Skills:
- Medical Knowledge: Proficient in medical terminology, diagnostics, and coding systems (ICD, CPT).
- Analytical Skills: Strong decision-making and attention to detail.
- Communication: Excellent verbal and written communication; bilingual proficiency is an advantage.
- Technical Proficiency: Experience with claims management systems and MS Office.
- Customer Focus: Empathetic and professional in handling inquiries and complaints.
- Time Management: Efficiently manages high volumes of requests.
- Teamwork: Collaborates effectively with stakeholders.
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