About the job
Job Family Summary:
The Operations Department is responsible to manage all aspects of claims management including Onsite operations and back end processing. The department primarily works on main objective of submitting the claims in time with highest quality to ensure the client receives the payment with minimal or no rejections.
Preapproval Department is based at the hospital site which manages precertification for all IPD and OPD cases for insured members contracted with the hospital as per designated networks.
Major role is at seeking preapproval for services with patient satisfaction-oriented duties.
The Associate Pre-Approval is responsible for registration and length of stay (LOS) assignment for all acute care hospitals admissions. Reviews and Discusses with nurses and physicians on denied cases or pending cases. Submits all requests, including required forms and limited documentation when requested, via DHPO/ websites. Notifies Hospitals by written notification of approval, rejection and denial of requests. Applies judgement in reconsideration for appeal of rejected cases.
Preapproval and Precertification for claims requiring approval.
Making Cost estimates according to procedures
Monitoring and follow up on prior authorization for outpatient/inpatient services
Scanning of cases to identify lack of documentation by physician/ reports prior to submitting to payer
Contacting the payers/TPA for approval related matters. Communicates adequately with external parties.
Contacting the physician/nurses for further clarification to make the claim eligible for preapproval.
Identify and analyze problems, take action to resolve, apply sound judgment and take responsibility for their resolution
Inform and influence others by clear, concise expression of ideas and information in verbal and written as appropriate
Timely and meets deadlines.
Reporting trends related to preapproval to reporting TL /Supervisor
Medical Background – Nursing /BAMS/BHMS/MBBS/BDS preferred.
Medical Coding knowledge preferred. Certification will be added advantage
Fresher for Junior Level post,
Medical Billing Knowledge with certification will be as well an added advantage.
Proficient in the software modules. (Microsoft Word and Excel)
Strong background of various insurance pre-authorization protocols and portals
Key Performance Indicators (KPI’s)
Completing the assigned/allocated preapproval claims as per TL/Supervisor >95% quality (error free) to be achieved on given tasks.
Strict Adherence to process and protocols of payers and as well organization
Maintain TAT for all approval within 24 to 48 hours
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