Job purpose:

To review, assess, evaluate, and manage preapproval requests on direct billing and reimbursement basis.

Contribute to case management efforts to meet team and departmental targets.

Arrange GOPs through international partners to clients requesting pre-approvals outside the GCC.

Support the MCS, Claims and CRM team with their queries and escalations.

Assist the team in provider visit to review cases ‘on the ground’ and aid in audits/FWA efforts.

Key Responsibilities:

• Ability to assess and process request for medical pre-authorizations.
• Achieve the pre-authorization SLA metrics.
• Support in evaluating the complex cases, including Inpatient.
• Evaluate the cases based on DRG and CPT/ICD coding.
• Visit providers to review medical files and information to aid in case processing.
• Support the FWA team with on ground provider audits (as and when required).

Operational & Technical Responsibilities:

• High level of working knowledge of healthcare regulations in Oman (and other GCC countries, particularly: UAE, Qatar, and Bahrain) to be considered as part of processing.
• Strong communication (verbal & written) to stakeholders, including providers and internal teams.
• Sound knowledge and following of all medical insurance guidelines.
• Understand the different aspects of the Healthcare Platform to be able to direct queries to the relevant parties where necessary.
• Contribute significantly to the departmental savings via case management and other initiatives.

Essential Requirements:

• Medical or paramedical degree
• Should have minimum 3 years’ experience in health insurance.
• Should have Minimum 3 yrs years’ experience in preapproval department.
• Good CPT, ICD and DRG knowledge
• Certification in medical coding is an advantage