Job Description

1. JOB PURPOSE

The Jobholder serves providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining database. He / She should provide accurate and relevant medical coverage details, maintain pre-approvals and claims processing and adjudication cycle within NHS software systems as per the defined terms and policies of the organization; He/ She will be guided by the regulations laid down by the regulatory authorities such as MOH, DHA or others.

2. RESPONSIBILITIES AND DUTIES

§ To issue online and verbal authorizations based upon member coverage & medical justification.

§ To assist queries from providers and payers via phone calls or e-mails

§ To maintain files for authorizations and other reports.

§ Assessing and processing claims in line with the policy coverage and medical necessity.

§ Be fully versed with medical insurance policies for various groups / beneficiaries.

§ Might be required to assist in training colleagues and sharing knowledge.

§ Able to accurately assess eligibility within the UAE (HAAD and DHA) guidelines as well as policy boundaries.

§ Monitoring and maintaining the claims processing and adjudicating cycle in NHS operational software system as per the defined terms and policy of the organization.

§ Establishing strategies and implementing effective parameters for solving all possible queries within the team.

§ Taking a lead role in assuring that the assigned tasks to the team are completed within the allocated time frame.

§ Ensures the proper communication and implementation of new formats, training and processing rules.

§ Entering and processing/ adjudicating claims in NHS operational software system as per the terms and policy of the organization.

§ Taking initiatives to maximize team efficiency.

§ Maintaining both qualitative and quantitative claims measures.

§ Ensure adherence to the predefined TATs for claims and pre-approvals

§ Achieving required processing targets assigned by the team leader on daily, weekly and monthly basis.

§ Monitor the qualitative and quantitative measures for claims & pre-approvals.

§ Ensure compliance to any changes in terms of system parameters or process.