Pre-Authorization Officer - IP

Job Description

• Checks all necessary documentation met for Preauthorization application with Insurance companies.
• Any missing document to be highlighted & communicated clearly to initiators and followed up for furnishing appropriate critical details for passing and completion in 1 communication.
• Attends duty as per 24/7 day format and shall be responsible for a replacement from team on not being able to attend without any deficiency to unit’s activity. Available as per Rota set by Preauthorization Supervisor for attending to the enquiry of the off hours staff in the Hospital.
• Obtaining Approvals for Inpatient treatment for both In House & CBD Doctors.
• Upload the Approval Requests with cost Estimate, ICD & CPT Codes on the respective online portal of the Insurance Companies.
• Coordinate with the CBD Clinics and Doctors regarding their Surgery Approval Requests.
• Update the Approval status via emails to the Doctors, Nurses and Admission team.
• Call and update the patients about the status of their Approval Request.
• Communicate and update Cashiers, Receptionist and all concerned colleagues regarding the latest updates from the Insurance Companies about the new cards, coverage, policies and procedures.
• Answer all calls related to the Insurance Queries and help the patients on their Reimbursement claims etc.
• Coordinate with Doctors & nurses with issues related to approval request.
• Train and orient new Doctors & Nurses on Insurance Protocol, Approval Requirements, exclusions & latest updates.
• Coordinate with the outside referral clinics /Hospital and CBD clinics for Approval related issues.
• Advise the patients/front desk staffs on the Card eligibility and Insurance Coverage details.
• Coordinate and help the dispatch team to solve the queries related to Inpatient approvals.
• Handling patient complaints & Queries related to the Insurance issues.
• Applies for Annual leave according to the Annual Leave plan.
• Follows up to coordinate completed documentation in the E.H.R or the files for needful reporting as needed by Insurance companies.
• Once approval is completed filed in the correct chronological order (physically & digitally) for the needful reference and forwarding then on to the Profiles unit.
• Needs to update oneself on all Insurance Company protocols, exclusions, Preauthorization details etc.
• Keep abreast of oneself on the latest medical trends etc. that are requisite for the proper conducting of one’s job.
• Maintains KPI for the Authorization along with documentation for future referral and auditing. Any Lapse to be immediately recorded with reason and highlighted to Supervisor.
• Any risk case whereby uncovered condition is discovered , or payment collection matters are involved, immediately escalates to the Preauthorization Supervisor and Insurance Manager.
• Checks requirements for all IP cases & gives counsel to the treating Doctors on what else to provide to reduce the TAT for Preauthorization.
• Supervises in reducing the gap between Approval Requester & Insurance Companies.
• Does study on regular trends of the Insurance Companies & reports to the Preauthorization Supervisor with possible action plans to mitigate risk for Hospital.
• Workable knowledge of the CPT, HCPCS, etc required & has to be updated regularly. Needs to take training for this on regular basis.
• Attends to complaints & resolves the same along with Preauthorization supervisor.
• Weekly statistics & daily reports: IP Admission & Discharge Statistics, IP Preauthorization Statistics, Compliance issues, Pending Preauthorization Statistics, Rejected Preauthorization Statistics, Revoked Preauthorization Statistics, Complaints record reported as and when raised
• Process flow charts given has to be adhered to , any change to be initiated as a change request & discussed with Preauthorization & Profile supervisor for changing.
• Desk Top Procedure of the Preauthorization Unit to be adhered to.
• Regular training given in respect to the area of work to be attended to without fail.