Description

Job Description

Key Accountabilities:

• The job holder will be responsible for managing day-today activities of pre-approval function including processing of pre-approval requests.
• The employee would be responsible for monitoring, maintaining, and improving transactional quality of the activities within the team and driving standards.
• Ensure all pre-approval requests are processed with 100% accuracy and in accordance with regulatory/clinical guidelines.
• Ensure implementation of all regulatory advisories and protocols. Optimization of the productivity of the team through operational efficiency.
• Providing constant and structured feedback to the Clinical Governance and Provider Management team to take corrective steps.
• Continuous improvement of processes, identify areas of opportunities and suggest improvement.
• To provide guidance, training and regular performance reviews/feedback to the team based on findings. Maintaining superior member experience, timely redressal of grievances.
• Managing daily operational activities of medical call center. Ability to attend calls of providers/members/partners.

Job Requirements:

• Timely processing of pre-approval cases; manage out/inpatient cases (inflow/outflow).
• Coordinate with providers for case management.
• Prudent adjudication of PBM approvals.
• Ensure effective communication with provider.
• Negotiate cost with providers, ensure correct length of stay of inpatient cases and effective implementation of insurance protocol/DRG billing.
• Coach pre-approval staffs and ensure all regulatory guidelines issued by the various regulatory bodies are adhered within day-to-day operations.
• Analyze data, prepare and present analytical report to management. 100% compliance of ePAR process and guidelines.
• 100% adherence of pre-approval TAT and authority matrix. Visit providers to manage inpatient cases, review DRG codes/severity levels submitted by healthcare facilities.
• Coordinate with physicians/providers efficiently and understand complete progress during patient’s hospitalization.

Job Qualifications:

• Jobholder must be energetic and possess ability to learn quickly in fast paced environment.
• Strong attention to detail; high degree of speed and accuracy.
• Strong proficiency in handling computer and software skills.
• A graduate of MBBS
• At least 5 years of relative work experience
• Knowledge of MS Office especially in MS-Excel
• Knowledge of the full know-how of UAE insurance industry and regulatory environment
• Interpersonal and influencing skills
• Problem solving and decision-making capabilities
• Good command over English (Written, Spoken & Reading)
• Ability to work under pressure and to do multi-tasking
• Good communication, negotiation, presentation, and interpersonal skills