Officer - Medical Authorization

Transguard Workforce Solutions is the UAE’s leading provider of unique and innovative HR solutions. With a decade of experience in the region and a team that possesses extensive knowledge of the market, we provide a fully integrated HR solution.

We are recruiting a Officer - Medical Authorization for our client, based out of their Abu-Dhabi office.

Key Responsibilities:

The job holder is responsible for all aspects of the prior authorization process including collecting all the necessary
documentation, contacting the customer/network provider for additional information and completion of the required prior authorization in order to proceed with service request. This job also requires to ensure complete, timely, and accurate identification and submission of prior and retro authorization requests.

• Policies, Processes and procedures:
  Follows the departmental adherence to all relevant policies, processes, standard operating procedures and instructions so that work is carried out in a controlled and consistent manner.
• Medical Authorization Activities:
  Verifies the requests with insurance policy; interpret medical information such as diseases or symptoms, and
  diagnostic descriptions and recommended procedures for treatment and determine if requested procedures
  are justified.
• Liaises with Supervisors, Officers and Medical Coding Coordinator to evaluate medical record documentations
  to ensure that diagnostic and recommended procedural codes accurately reflect and support the treatment of
  the disease or symptom, and to ensure that data comply with legal standards and guidelines.
• Approves medical authorization requests (as per delegated authority) if they comply with all stipulations and
  forward them to the Supervisors for final approval. Forward approved medical authorization requests to the
  provider and ensure proper record keeping.
• Handles all calls from Pharmacies or follow up calls on medical authorization. Support clients/providers on
  any medical authorization related queries, follow ups, emails or fax.
• Rejection of Claims:
  Coordinates with Doctors/Providers on medical authorization procedure requests if they are not acceptable and recommend appropriate alternate approaches. Recommend rejection of request for the manager to approve along with justifications.
• Continuous Improvement:
  Reviews periodically medical claims policies and procedures, identify operational gaps and propose recommendations and solutions to address these gaps in order to keep pace with the growth of the organization
• Reports:
  Provides Management with appropriate reports regarding the unit and compliance with operational policy and procedures.