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