Medical Officer Inpatient Precertification is responsible for managing the Inpatient Precertification cases while ensuring that departmental goals, timeline of activities, and compliance measures are met.
What you do
Precertification team is functional on 24/7 basis. Therefore the Medical Officer will be working on flexible shift basis as per the schedule provided by the Team Leader.
Adjudicates Cases at IP precertification level, authorizes decision within the stipulated turnaround time & with the highest quality standards in view with the policy terms and conditions
Performing complete file review with regards to the multidisciplinary notes, TPR charts, physician order s notes, lab reports, radiology reports, drug chart sheets, consultation notes, nursing notes, progress notes, etc.
Requesting any medical documentation or finding any missing document which is essential in decision making.
Performing review of DRG Severity of Illness (SOI) in line with revision of CPT codes / ICD codes, which are being up-coded by the provider if required discussion with the treating doctor and the medical coders.
Performing utilization review for DRG cases and FFS cases with regards to and not limited to final bill review + consumables mark ups + non covered item/services + overutilization of services.
Performing review of claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA,DOH/HAAD,MOH).
Adhering to the cost containment protocols for medical management cases.
Referring cases for second opinion when deemed necessary to confirm the best mode of management also for cost containment to lesser Negotiating factor (NF) facilities within the member s network or option for home country treatment.
AI READINESS Work effectively in an environment shaped by artificial intelligence (AI), machine learning, data, analytics and cloud-based tools, using insights responsibly with our standards of data governance, security and ethical use.
What you bring
Bachelor s of Pharmacy / Dentistry / Medicine / Nursing / Physiotherapist / Paramedics
01-02 years of Medical Practical Experience (reputable insurance provider, broker or a TPA experience a plus) OR Entry Level
Physically fit to carry out duties.
Certified Medical Coder [Preferable]
Legally permitted to work in the country of operations.
Physically fit to carry out duties.
Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.
