Prior Approvals Officer

Key Responsibilities & Accountabilities

Develop and maintain a comprehensive understanding of insurance operational guidelines, standard operating procedures (SOPs), policy terms, and legal frameworks.

Acquire technical proficiency to effectively manage system-related issues, including bug reporting and outage resolution.

Rigorously validate medical request documentation submitted via ticketing or online systems.

Adhering to established operational guidelines and SOPs.

Accurately input request data into the system, ensuring thorough database maintenance and documentation prior to decision-making.

Thoroughly assess medical requests, gathering all necessary information to support informed decision-making.

Suspend requests requiring further investigation and resolve them within quality standards.

Proactively identify fraudulent request patterns, flag suspicious cases for investigation, and report wasteful practices to relevant departments.

Respond to inquiries and requests from internal departments, including Customer Service, Client Relations, Claims, Fraud Waste & Abuse, Sales, and Complaints, within authorized boundaries and department guidelines.

Collaborate with other departments to resolve complex requests and propose solutions to prevent recurrence.

Maintain flexibility to work shifts as determined by supervisors and managers to align with capacity planning and operational needs.

Maintain full compliance of department to AXA standards and reactivity/contribution to all compliance processes.

Job Specifications

Education / Certification

Bachelor of pharmaceutical sciences

0-3 Year of Experience

Soft Skills & Behavioral Competencies

Pharmaceutical Practice / Medical Practice.

Strong interpersonal and customer service orientation.

Proficiency in computer applications.

Ability to multitask and prioritize tasks effectively.

Strong problem-solving and decision-making skills.

Attention to detail and accuracy.

Knowledge of insurance products and processes (preferred)