Job Description

Roles & Responsibilities

This role involves reviewing and assessing proposed medical treatments to ensure compliance with policy terms while meeting clients' healthcare needs in a cost-effective manner. The candidate will communicate directly with clients regarding pre-approval queries and collaborate with various teams to monitor cases of potential fraud and high utilization. Additionally, the position requires the ability to generate reports and assist in maintaining quality audit standards.

Responsibilities:

• Reviews daily proposed inpatient hospital confinement, outpatient surgeries, outpatient laboratory tests, physiotherapy, MRI / CT scan tests for decision, etc.
• Reviews daily insured's Policy terms and conditions, insured claims history, medical facility, and any other health care provider to assure that the insured s specific medical needs are met in the most cost-effective setting suitable for treatment of the injury or sickness and matching his policy benefits.
• Reply on daily basis to client queries related to pre-approvals by phone, email or any other means of communication.
• Refers to any suspected cases with no need for extension of admission to case management team.
• Assists in weekly reports highlighting any abuse, fraud or high utilization from insured, providers or policy holders in collaboration with C.S/Approvals doctor.
• Refers all cases for price approval to network team.
• Monitors cases for anti-selection and investigates with portfolio management team.
• Meets quality audit requirements.
• Handles on daily basis any other assignment as required or appointed by the heads of department.

Desired Candidate Profile

• Bachelor s degree in Medicine or a related field from an accredited institution.
• Minimum of 5 in healthcare insurance, medical review, or case management.
• Strong understanding of insurance policies, medical terminology, and healthcare regulations.
• Excellent communication and interpersonal skills, with proficiency in responding to client queries effectively.
• Ability to analyze medical cases and claims history to make informed decisions.
• Strong organizational skills and meticulous attention to detail for quality assurance.
• Familiarity with healthcare management systems and Microsoft Office Suite.