ob Description

Roles & Responsibilities

• 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.
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• 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.

Desired Candidate Profile

• 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
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