Medical Claims jobs

1. JOB PURPOSE

The job holder for preauthorization is responsible to review and approve medical services requested by providers or customers according to medical necessity review guidelines. He/she will ensure customers receive the best quality care, diagnostic and treatment, along with avoidance of over or under utilization of clinical services. Should provide accurate and relevant medical coverage details and work with a multicultural population and is constantly aware of the cultural differences among that population and the geographical regions.

2. RESPONSIBILITIES AND DUTIES

• Part of a clinical team that provides medical management services to customers worldwide but mainly in Middle East and Africa region.
• Give evidence-based advice on pre-authorization, considering internationally accepted protocols and local and/or regional customs and regulations.
• Assessing pre-authorization requests claims in line with the policy coverage and medical necessity.
• Identify and refer cases to the Cigna Clinical Programs team for case management, disease management and other clinical services.
• Assist is the coordination of processes for improving quality of care and health outcomes for specifically delineated projects or populations.
• Assist and support the team in cost containment, assist in projects and service delivery to meet goals.
• To assist queries from providers and payers via phone calls or e-mails
• Be fully versed with medical insurance policies for various groups / beneficiaries.
• Might be required to assist in training colleagues and sharing knowledge.
• Ability to review, investigate, and respond to external and internal inquires/complaints and provide guidance to other clinical and non-clinical staff related to medical necessity.
• Assist in fraud detection
• Meeting the defined qualitative and quantitative key performance metrics for the assigned job role.
• Ensure adherence to the predefined TATs for pre-approvals
• Achieving required targets assigned by the team leader on daily, weekly, and monthly basis.
• Ensure compliance to any changes in terms of system parameters or process.
• Other duties as assigned

3. KNOWLEDGE, SKILLS AND EXPERIENCE

• University degree of Medical /Para-medical specialization with international healthcare experience.
• 2-3 years of clinical experience preferable in a payer setting on medical management.
• Strong interpersonal and communication skills.
• Ability to operate a personal computer, proficient with Microsoft office products, call centre software and a variety of software for medical management.
• Knowledge of utilization/case management, cost containment services, managed care, insurance coverage, and financial management a plus.
• Ability to build solid working relationships with staff, matrix partners, clients, customers, and healthcare providers.
• Demonstrates pro-active problem-solving and analytical skills
• Stress resistant and efficient, finding a good balance between quality and quantity
• Ability to speak, write and read English, any other language a plus
• Flexible to work on shifts/team schedule

Pay: AED7,000.00 per month

Application Question(s):

• Willing to work in flexible shifts/team schedule?

Experience:

• Medical insurance: 2 years (Required)

Work Location: In person