Associate, Preauthorization

Overview

The Associate, Preauthorization will oversee medical auditing, pre-authorization administration, fraud control, and customer service assurance in a healthcare insurance context. This role ensures comprehensive case management and cost control through collaboration with healthcare providers.

Key Responsibilities

• Manage case coordination with providers to control costs and ensure efficient case progression.
• Handle customer queries effectively, aiming for first-time resolution (FTR).
• Meet established service level agreements (SLAs) for inpatient and outpatient adjudications.
• Respond to inquiries from clients, brokers, and providers promptly.
• Escalate unresolved customer issues in accordance with policies and turnaround expectations.
• Support the daily operations of the pre-authorization (PAR) unit, which operates 24/7.
• Ensure unit key performance indicators (KPIs) and both internal and external SLAs are consistently met.
• Assist in implementing medical pre-approval procedures and compliance with regulatory directives.
• Conduct onsite inspections to audit and detect suspected fraudulent provider activities, reporting findings to fraud and network teams.
• Review, audit, and finalize pending medical approval requests.
• Maintain management information systems (MIS), quality control processes, and standard operating procedures (SOPs) relevant to the unit.

Qualifications and Skills

• Possess a medical degree or relevant clinical qualification with significant experience in health insurance operations.
• Proven track record in medical auditing, pre-authorization, claims adjudication, and controlling fraud, waste, and abuse.
• Deep knowledge of healthcare systems, insurance policies, and regulatory requirements.
• Strong decision-making skills with proven ability to authorize eligible medical cases accurately.
• Excellent command of English, both written and spoken; Arabic language proficiency is a plus.
• Skilled in information technology, including MS Office, healthcare claims management systems, and reporting tools.
• Understanding of medical coding standards such as ICD and CPT is desirable.
• Experience with business process improvements like process mapping and workflow optimization.
• Familiarity with quality methodologies such as Lean and Six Sigma.
• Ability to prioritize tasks effectively in a 24/7 operational environment while meeting SLA, KPI, and compliance requirements.