Job Description

Roles & Responsibilities

Providing approval of services for the insured member through DHPO, email and PBM, over riding of rejected medication if falls under policy t&c and if clinically justified.

Providing excellent customer service through responding swiftly to queries from insured member, medical provider .

1. Provide approval through online system(DHPO), emails and call to Medical provider according to medical necessity and as per policy wordings.
2. Coordinate between Insurer, patient and provider.
3. Handles phone calls and written inquiries related to requests for pre-Approvals/pre authorizations, reconsiderations, or appeals.
4. Performs a comprehensive review for the record to assure thepresence of all component parts such as patient and record identification, signatures and dates where required and other necessary data in the presence of all reports which appear to be indicated by the nature of the treatment rendered.
5. Handing pharmacy rejection and approving the same if matches with indications and policy wordings.
6. Processing pharmacy and op clinics claims at the end of the every month.

Desired Candidate Profile

• Qualifications: Education : Bachelor of Pharmacy/Bachelor of Nursing Experience : Insurance experience is preferred