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

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.