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Medical Approvals

1.00 to 10.00 Years   Saudi Arabia   25 Feb, 2025
Walaa Cooperative Insurance Company
100 to 499 Jobs Openings
Job LocationSaudi Arabia
EducationNot Mentioned
SalaryNot Mentioned
IndustryInsurance & TPA
Functional AreaNot Mentioned

Job Description

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.

Keyskills :

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