Approval Officer

JOB SUMMARY • Apply medical knowledge and best insurance practices while reviewing and verifying Pre-Approval requests (OP/IP) received from different departments to obtain authorizations as required by insurance companies, depending on the plan coverage for all insurance patients. • Ensure that Pre-Authorization Requests comply with regulatory standards, particularly claim adjudication rules and business rules. • Handle rejected Pre-Authorization requests and obtain the required justification from the treating doctor for resubmission to the insurance company and approval. • Prepare daily activity reports as requested by management and assist with month-end reporting as required. DUTIES AND RESPONSIBILITIES • Evaluate Pre-Approval requests for medical necessity based on the medical information provided. • Accurately code service description codes stated on prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and the policy schedule of benefits. • Respond to Insurance/TPA queries and liaise with concerned departments without delay. • Receive, evaluate, and escalate second-opinion cases and case management requirements as appropriate. • Prepare daily activity reports and assist with monthly reporting as required. • Attend meetings and presentations as required. • Adjust and manage duties in the event of sudden, emergency, or unplanned leave of colleagues to ensure continuity of operations. • Manage and hand over pending cases, if any, to colleagues in the next shift. • Perform any other duties or responsibilities assigned by the HOD from time to time within the scope of the job title. • Bachelor’s degree in Medicine or an equivalent medical degree from a recognized university. • Minimum 2 years of experience in insurance claims management/adjudication. • Knowledge of medical coding systems, including ICD, CPT, DRG, and HCPCS. • Excellent command of both written and spoken English. • Flexible and able to work under pressure and in shifts. • Proficiency in Microsoft Office applications.