Job Description
OVERALL PURPOSE:
Senior Specialist Pre-Authorization
– To manage the initial assessments of medical requests daily and provide approvals/ pre-authorization to service providers to proceed with the treatment plan (medical procedure, prescriptions drugs, etc.). Negotiate cases with doctors to provide the best services for clients while ensuring cost efficiency, thus contributing to the profitability of the company.
Key Responsibilities:
1- Strategic Contribution:
Senior Specialist Pre-Authorization
– Contribute to the implementation and execution of the division’s short to mid-term plans assessing and providing pre-authorizations while monitoring compliance.
– Report key findings related to fraud detection and abuse for inpatient cases and recommend corrective actions to the management.
2- Operational:
Senior Specialist Pre-Authorization
– Process medical requests received from service providers on a daily basis and conduct initial assessments on in/ out medical patient cases.
– Provide approvals/ pre-authorizations on compliant patient services as required and in alignment with policies and procedures subject to fraud and abuse.
– Ensure that all approvals and pre-authorizations are done within a limited timeframe (under 15 minutes) in order to keep the patients waiting time to a minimum and improve customer satisfaction and experience.
– Ensure that the medical service provider members in the designated network are up to standards, qualified, and in compliance with ART’s policies and procedures.
– Assist in analyzing fraud incidents in order to prevent them from reoccurring and to support management in taking adequate decision-making and corrective actions.
– Contribute to the delivery of pre-authorization training and campaigns in order to strengthen capabilities within ART.
– Conduct investigations and audits on medical records as needed with medical providers in order to address any malpractice, misconduct, and fraudulent activity, provide recommendation measures, and be in compliance with ART’s policies and procedures.
– Contribute to building sustainable relationships with key stakeholders across medical providers by demonstrating strong communication skills.
– Manage the timely dissemination of contractual information within the organization to relevant stakeholders.
– Resolve any escalated issues rapidly and efficiently.
3- Policies, Systems, Processes & Procedures:
Senior Specialist Pre-Authorization
– Follow all relevant departmental policies, processes, standard operating procedures, and instructions to ensure work is carried out in a controlled and consistent manner.
4- Continuous Improvement
– Contribute to the identification of opportunities for continuous improvement of processes, productivity, and cost reduction related to own work.
5- Reporting
– Ensure that all relevant periodic and ad-hoc reports are prepared timely and accurately, and meet the function’s requirements, policies, and standards.
6- CyberSecurity
– Responsible for complying with cyber security policy, standards, and procedures
Academic Qualifications and Experience:
– Bachelor of Medicine or Doctor of Medicine or other relevant fields
– 1-2 Years of Experience
– English Proficiency
Skills
– Bachelor of Medicine or Doctor of Medicine or other relevant fields
– 1-2 Years of Experience
– English Proficiency
