Job Summary:

The Medical Approval Specialist is responsible for reviewing and approving payment on  pre-approvals received from hospitals/clinics between $1 & $5,000; the incumbent will respond to all members/clients queries ensuring high level of customer medical necessity and satisfaction.

Main functions and responsibilities:

1. Review and approve payment against  Pre-approval received from hospitals/clinics on medical cases between $1 and $5,000 after review of medical reports,   documents & insurance details making sure they are in accordance with required conditions and policy terms.

2. Consult with the Provider Relation Department for any discrepancy in price or CPT code of the provider  pre-approval.

3. Coordinate & follow up with Clinical Team for any complex admission case.

4. Respond to clients/members calls and queries related to their  pre-approvals status  , eligibility, plan benefit coverage and other queries related to member’s policy terms & conditions.

5. Handle medical cases related to areas of specialization.

6. Book every call/ complaint and Support the Customer Service Department for any query related to clients’  pre-approvals.

7. Assist in the department process improvements and make recommendations to Team Leader.

8. Process requests for pre-certification from providers (hospitals/clinics) in the approvals module of the Company’s Claims Management System (CMS) by applying policy terms and conditions.

9. Adhere to the contents of the Operating Procedures Manual (OPM) and the Company’s overall procedures and policies.

10. Miscellaneous tasks within the scope of work, as assigned by the direct manager.

11. Schedule on rotated shifts and weekends as assigned by the direct manager.

Education/ Certifications

MBBS degree

Practical/ Technical Experience

2 years’ experience, preferably in health insurance field