Main responsibilities (minimum of 3 key points in category please) will include:
Key Responsibilities
- Adjudicating and Processing insurance pre-approvals in a timely and accurate manner following Claims policy. Within the agreed TAT per line of business
- Providing preapproval for medical claims based on medical eligibility and policy terms.
- Implement cost containment through Guidelines and proper medical adjudication.
Operational & technical responsibilities
- Sound knowledge of all medical insurance and guidelines
- Ability to understand the different aspects of the Healthcare Platform to be able to direct queries to the relevant parties where necessary.
- Requires a basic understanding of the reasons for inclusion/exclusion of certain treatments or conditions.
- Sound knowledge of regulations from a regulatory authority.
- Considerable degree of independent thought and judgment to evaluate medical decisions on an objective basis.
- Decide on pre-approval based on medical necessity and policy terms & conditions.
- Reporting of provider abuse if it is found to be recurrent as part of the cost-containment strategy of the health care operation.
- Individual quality monitoring
Requirements:
- Essential: 2-3 years experience preferably within the health care industry.
- Medical / Nursing qualification
- Flexibility to work in 24/7 Shifts
- Desirable: Sound medical knowledge.
- Good analytical skills
- Preferably with Medical insurance background
- Preferably worked in approvals department
- Customer-focused
- Strong communication (verbal & written)
- Ability to work effectively within a team environment
- Highly motivated and proactive
- Results-driven and solution-orientated
