Job Summary:
The Senior Medical Approval Officer is responsible for leading the review, processing, and auditing of medical approval requests while ensuring full compliance with insurance policies, clinical guidelines, and Revenue Cycle Management (RCM) processes. The role requires extensive experience in medical insurance operations within the Saudi healthcare market, with a strong focus on minimizing claim denials, optimizing revenue cycles, and supporting operational excellence.
Key Responsibilities:
RCM Leadership: Manage medical approvals as a critical component of the Revenue Cycle Management (RCM) process to reduce claim denials, improve reimbursement rates, and optimize revenue. Complex Approval Processing:Review, validate, and process complex medical approval requests accurately while maintaining the required Turnaround Time (TAT). Compliance & Medical Review:Verify patient eligibility, provider network status, medical necessity, and policy coverage in accordance with insurance regulations and company guidelines. Denial & Appeals Management:Investigate rejected approval requests, coordinate with healthcare providers and insurance companies, prepare appeals, and ensure timely resubmission with complete documentation. Quality Assurance & Auditing:Conduct regular audits of approval decisions, identify trends, ensure compliance with internal policies, and recommend process improvements. Data Analysis & Reporting:Generate analytical reports on approval performance, rejection trends, KPIs, and operational efficiency using advanced Microsoft Excel. Stakeholder Management: Collaborate effectively with healthcare providers, insurance companies, medical teams, and internal departments to resolve complex approval cases and improve workflow efficiency. Process Improvement: Support the implementation of best practices, mentor junior approval officers, and contribute to continuous process optimization.
Qualifications & Requirements:
Bachelor's degree in Pharmacy or a related healthcare field. Minimum 4 years of proven experience in medical approvals, medical insurance operations, medical auditing, or utilization management. Hands-on experience in the Saudi healthcare and insurance market is mandatory. Strong knowledge of Revenue Cycle Management (RCM), medical claims processing, pre-authorization, and medical billing workflows. Solid understanding of Saudi insurance regulations, payer policies, and approval guidelines. Advanced proficiency in Microsoft Excel, including formulas, pivot tables, reporting, and data analysis. Familiarity with medical coding standards and healthcare insurance systems is preferred. Excellent analytical, problem-solving, and decision-making skills with exceptional attention to detail. Strong communication, negotiation, and stakeholder management skills. Ability to work under pressure, manage priorities, and consistently meet service level agreements (SLAs) and turnaround times (TATs).