The Health Authorization Specialist is responsible for reviewing, processing, and adjudicating health claim requests received from TPAs in accordance with policy coverage, clinical guidelines, regulatory requirements, and service-level agreements. The role ensures that medically necessary services are appropriately authorised while maintaining member satisfaction, cost management, and compliance standards.
Responsibilities
- Receive and review authorization requests submitted by TPA's.
- Verify member eligibility, benefits, policy coverage, and authorization requirements.
- Evaluate requests against policies, clinical guidelines, medical necessity criteria, and contractual agreements.
- Coordinate with Medical Directors, clinicians, and case management teams for clinical reviews when required.
- Approve, modify, or deny authorization requests in accordance with established guidelines.
- Communicate authorization decisions to TPA's and stakeholders within defined turnaround times.
- Request and review additional medical records or supporting documentation when necessary.
- Maintain accurate records of authorization decisions and supporting rationale in the claims/authorization system.
- Ensure compliance with regulatory requirements, accreditation standards, and company policies.
- Support appeals and reconsideration processes by providing authorization documentation and case history.
- Monitor authorization queues and ensure adherence to operational SLAs.
- Identify trends in authorization requests, denials, and provider inquiries for process improvement initiatives.
- Collaborate with Claims, Provider Relations, Utilization Management, Case Management, and Customer Service teams.
Qualifications
- MBBS / MD or equivalent medical degree recognized by the relevant health authority.
- 3–7 years of clinical practice and/or health insurance claims management experience.
- Experience in preauthorization, utilization management, medical claims review, or managed care preferred.
- Knowledge of medical terminology, disease conditions, and treatment protocols.
- Familiarity with ICD-10, CPT, HCPCS, and DRG coding systems.
- Strong analytical, communication, and decision-making skills.
- Familiarity with health insurance regulations and healthcare reimbursement processes.
- A physician with strong experience in the UAE health insurance claims process, possessing a comprehensive understanding of DOH, DHA, and MOHAP regulations.
