Claims Officer - Pre approval - Insurance TPA

Claims Officer - Pre approval - Insurance TPA

The Jobholder serves providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests, and maintaining the database. He/She should provide accurate and relevant medical coverage details, maintain pre-approvals, and manage the claims processing and adjudication cycle within NHS software systems as per the defined terms and policies of the organization. He/She will be guided by the regulations laid down by the regulatory authorities such as MOH, DHA, or others.

RESPONSIBILITIES AND DUTIES

1. Issue online and verbal authorizations based upon member coverage & medical justification.
2. Assist queries from providers and payers via phone calls or e-mails.
3. Maintain files for authorizations and other reports.
4. Assess and process claims in line with the policy coverage and medical necessity.
5. Be fully versed with medical insurance policies for various groups/beneficiaries.
6. Assist in training colleagues and sharing knowledge.
7. Accurately assess eligibility within the UAE (HAAD and DHA) guidelines as well as policy boundaries.
8. Monitor and maintain the claims processing and adjudicating cycle in NHS operational software system as per the defined terms and policy of the organization.
9. Establish strategies and implement effective parameters for solving all possible queries within the team.
10. Assure that the assigned tasks to the team are completed within the allocated time frame.
11. Ensure proper communication and implementation of new formats, training, and processing rules.
12. Enter and process/adjudicate claims in NHS operational software system as per the terms and policy of the organization.
13. Take initiatives to maximize team efficiency.
14. Maintain both qualitative and quantitative claims measures.
15. Ensure adherence to the predefined TATs for claims and pre-approvals.
16. Achieve required processing targets assigned by the team leader on daily, weekly, and monthly basis.
17. Monitor the qualitative and quantitative measures for claims & pre-approvals.
18. Ensure compliance to any changes in terms of system parameters or processes.

KNOWLEDGE, SKILLS AND EXPERIENCE

1. University degree in any discipline of Medical/Para-medical specialization from a reputable university.
2. Healthcare/Hospital experience for 1-2 years in departments such as Surgery, ICU, or GP is required.
3. 1-2 years of work experience in the Insurance industry is preferable but not mandatory.
4. Excellent oral and written communication skills.
5. Must be computer literate.
6. Excellent command of the English language; Arabic is a definite plus.
7. Should be a team player with an aptitude for customer service; must be service-oriented.
8. Highly decisive with outstanding logic and reasoning skills.
9. Must be tactful and discrete while dealing with Providers or Payers; must be able to handle confidential information.
10. Ability to work under pressure and meet tight deadlines and varying work schedules.