Approval Officer

D U TI E S A N D R E S P ON S I B I L I T I E S

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 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.

• Evaluate pre-approval requests for medical necessity based on the medical data provided.

• Accurately code service description codes on prior authorization requests in accordance with accepted medical coding rules, medical guidelines, and policy schedule of benefits.

• Respond promptly to Insurance / TPA queries and coordinate with the concerned departments without delay.

• Receive, evaluate, and escalate second-opinion cases and case management requests.

• Perform night-shift duties and work on public holidays as per the duty roster.

• Prepare daily activity reports as requested and assist management with monthly reports.

• Handle the auditing process by arranging required documents, coordinating with coders, and supporting external auditors.

• Attend meetings and presentations as required.

• Train front office staff, receptionists, and nurses, and keep them updated on insurance-related procedures and policies.

• Prepare cost estimates for procedures for cash-paying patients.

• Adjust duties during sudden or emergency unplanned leave of colleagues to ensure continuity of operations.

• Manage and hand over pending cases to the next shift colleagues.

• Perform any other duties assigned by the Head of Department (HOD) from time to time within the scope of the job role.

• Bachelor’s degree in Medicine (MBBS) from a recognized university.

• Minimum 2 years of experience in insurance claims management and/or adjudication.

• Hands-on experience in medical coding, including ICD, CPT, DRG, and HCPCS .

• Excellent command of written and spoken English .

• Flexible, adaptable, and able to work effectively under pressure.

• Strong proficiency in Microsoft Office applications (Word, Excel, PowerPoint, Outlook).