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Medical Approval Specialist

1 week ago

Khobar, Eastern Province, Saudi Arabia Walaa Cooperative Insurance Co. Full time
Job Summary

This role involves overseeing the pre-authorization process for medical services and ensuring compliance with policy terms. Key responsibilities include verifying eligibility, assessing requests, approving or denying them based on necessity and policy limits, communicating decisions to providers and policyholders, monitoring utilization trends, and identifying potential fraud, waste, or abuse.

Key Responsibilities
  • Medical Pre-Authorization: Verify eligibility and coverage of insured members, assess requests for medical services and treatments, approve or deny requests based on medical necessity and policy guidelines, communicate authorization decisions to providers and policyholders, and monitor utilization trends.
  • 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.