Pre-Approval Officer (IP/OP)

Job Description

• Review and verify the Pre-Approval requests (OP/ IP) received from different departments to obtain authorizations as required by insurance companies dependent upon the plan coverage for all Insurance patients.
• Ensure that the details of the Pre-Authorization Requests are in line with the regulators’ standards, especially the claim adjudication Rules and Business Rules. 
• Handle the rejected pre-authorization and get the required justification from the treating doctor to resend it to the Insurance Company and obtain the approval.
• Prepare reports of daily activity as requested for management and assist management in month-end reporting as requested.
• Evaluate the Pre-Approval requests from medical necessity for the requested service according to the medical data provided and accurately code the service description codes stated on the prior authorization requests, according to accepted medical coding rules, medical guidelines and policy’s schedule of benefits.
• Respond to Insurance/ TPA queries and liaise with the concerned department without any delay. 
• Responsible for receiving, evaluating and escalating second opinion cases and case management. 
• Prepares reports of daily activity as requested for management and assists management in monthly reports as requested. 
• Handle Auditing Process. Arrange required documents and papers and check with coders in order to assist the external Auditors. 
• Prepare cost estimate for procedures for Cash Patient