Approval Officer NMC healthcare LLC

Job Description

3.1 Evaluate the Pre Approval requests from medical necessity for the requested service according to the medical data provided and accurately code the service description codes stated on the prior authorization requests, according to accepted medical coding rules, medical guidelines and policy’s schedule of benefits
3.2 Respond to Insurance/ TPA queries and liaise with concerned department without any delay.
3.3 Responsible for receiving, evaluating and escalating second opinion cases and case management
3.4 Perform night shift duty and on public holidays as per duty roster.3.5 Prepares reports of daily activity as 3.5 requested for management and assists management in monthly reports as
requested.
3.6 Handle Auditing Process. Arrange required documents and papers and check with coders in order to assist the
external Auditors
3.7 Attend Meetings and Presentation
3.8 Train Front office, Receptionist and Nurses and keep them updated about Insurance details.
3.9 Prepare cost estimate for procedures for Cash Patient
3.10 To adjust duties in case of any sudden/ emergency unplanned leaves by colleagues.
3.11 Managing and handling pending cases (if any) to the next shift colleagues.
3.12 Performs any other jobs or duties assigned by the HOD from time to time within the scope of job title.
3.13 Comply with all OSH and infection control policies, standards and procedures and cooperate with hospital
management to comply those requirements
3.14 Work accordance with the documented OSH procedures and instructions, specific responsibilities
3.15 Be familiar with emergency and evacuation procedures
3.16 Notifying OSH Hazards, incidents, Near misses and issues and assistance with the preparation of risk
assessments, incident reports
3.17 Comply with Waste management procedures and policies
3.18 Attend applicable OSH/Infection control training programs, mock drills and awareness programs
3.19 Use of appropriate personal protective equipment and safety systems

Responsibilities

• Evaluate pre-approval requests for medical necessity based on the provided medical data, and accurately code service descriptions according to accepted medical coding rules, medical guidelines, and the policy schedule of benefits.
• Respond to Insurance/TPA queries promptly and coordinate with the concerned departments without delay.
• Receive, evaluate, and escalate second-opinion cases and case management as required.
• Perform night-shift duties and work on public holidays as per the duty roster.
• Prepare daily activity reports as requested by management and assist with monthly reports.
• Handle the auditing process, arrange required documents, and coordinate with coders to support external auditors.
• Attend meetings and presentations as required.
• Train front office staff, receptionists, and nurses, and keep them updated on insurance details.
• Prepare cost estimates for procedures for cash patients.
• Adjust duties as needed during sudden or emergency unplanned colleague absences.
• Manage and hand over pending cases (if any) to colleagues for the next shift.
• Perform any other tasks assigned by the HOD that fall within the scope of the job title.
• Comply with all OSH and infection control policies, standards, and procedures, and cooperate with hospital management to meet these requirements.
• Work in accordance with documented OSH procedures and instructions specific to assigned responsibilities.
• Be familiar with emergency and evacuation procedures.
• Report OSH hazards, incidents, near-misses, and assist in preparing risk assessments and incident reports.
• Comply with waste-management procedures and policies.
• Attend applicable OSH/infection control training programs, mock drills, and awareness activities.
• Use appropriate personal protective equipment (PPE) and safety systems.