Medical Officer - Specialist 1

Job Description-Pre-authorization

Job Purpose

To evaluate and adjudicate pre-authorization requests by reviewing medical details, policy terms, and insurer concurrence, ensuring accurate and timely approvals that contribute to effective processing and customer satisfaction.

Principal Accountabilities

1. Process pre-authorization requests Ensure timely and accurate adjudication (approval, rejection, or shortfall) - compliance with policy terms.
2. Review and validate medical details Check system entries and documents - maintain accuracy and reduce errors.
3. Refer cases requiring specialist input Escalate package deviations or complex cases -ensure appropriate medical decision-making.
4. Coordinate with insurers Obtain concurrence for approvals - smooth case closure and in line with Insurer guidelines.
5. Respond to medical queries from hospitals/customers Provide clear communication - enhance customer experience.
6. Follow internal guidelines and regulatory standards Maintain compliance - minimize audit observations.

Reporting Structure:

Reports To: Floor Manager – Pre-Auth

Major Challenges

• Managing high volumes of pre-auth requests within defined TAT.
• Managing accuracy with speed in decision-making.
• Handling escalations and complex medical cases effectively.
• Query Management with hospitals, insurers, and internal teams for quick resolutions.

Decisions

• Independent: Adjudication of standard pre-authorization cases as per policy terms.
• With Approval: Escalations requiring specialist opinion, insurer concurrence, or deviations from package norms.

Interactions

Internal: Pre-Auth Team, Case Management, CRM team.

External:

• Hospitals through Query (for discharge summaries, clarifications, and missing documents).
• Insurers (for concurrence and escalations).

Qualifications & Experience

• Education: Graduates -BHMS/BAMS/BDS
• Experience:
  1. Fresher medical graduates can apply.
  2. Prior experience in Pre-Authorization in a TPA or HealthTech setup preferred.
  3. Exposure to authorization processes is an added advantage.

Other requirements:

• Strong medical knowledge with willingness to work in a non-clinical process.
• Prior experience in pre-authorization or claims (preferred).
• Flexible to work in shifts and from office (no WFH).
• Prior HealthTech / TPA experience is an advantage.