متخصص الموافقات

Key Responsibilities and Duties: 1. Ensure full adherence to the Council of Health Insurance (CHI) Preauthorization Policy, NPHIES standards, and individual payer coverage protocols. 2. Prevent unauthorized, uncovered, or non-contracted services from being initiated. 3. Support the implementation and compliance of NPHIES downtime contingency procedures. 4. Verify the completeness of clinical documentation and utilization of the Minimum Data Set (MDS) for every request. 5. Review the treating physician’s progress notes, diagnostics, prescriptions, and clinical justifications for accuracy and adequacy. 6. Validate medical necessity in alignment with evidence-based guidelines, CHI standards, and payer criteria. 7. Ensure accurate clinical coding and scheme linkage to prevent claim denials. 8. Escalate incomplete or inaccurate documentation for correction prior to submission. 9. Liaise with treating physicians, nurses, and roving doctors to secure approvals and clarify case details. 10. Communicate approvals, denials, and payer queries within CHI-mandated timelines. 11. Respond to payer or insurer queries within 30 minutes of receipt. 12. Escalate urgent or high-priority cases (ER, ICU, Oncology, or high-cost procedures) immediately to the Preauthorization Manager. 13. Monitor HIS/NPHIES queues to follow up on pending or queried cases in real time. 14. Maintain updated approval status in both HIS and the patient’s record. 15. Ensure 100% completion of approvals for all discharges within the same day. 16. Confirm that same-day discharge and high-cost cases are fully approved prior to billing. 17. Document all approvals, denials, and payer communications in the patient’s medical record. 18. Participate in the daily discharge reconciliation process and report pending approvals to the Preauthorization Manager. 19. Review all preauthorization rejections received through NPHIES, payer portals, or HIS at least twice per shift. 20. Categorize rejections based on cause (missing justification, duplication, non-covered service, exceeded limit, coding error, or late submission). 21. Record all rejections in the Rejection Tracker Log with patient MRN, preauthorization number, payer, rejection reason, and physician name. 22. Coordinate with the Preauthorization Supervisor to ensure each rejection is reviewed and analyzed within the assigned TAT. 23. Engage directly with the treating physician for clarification or missing documentation related to rejected cases. 24. Provide constructive feedback and guidance to physicians to avoid recurrence, referencing insurer preauthorization protocols, CHI guidelines and NPHIES dataset requirements. 25. Conduct same-day briefings for rejections involving high-cost services. 26. Resubmit corrected documentation within the payer’s appeal window as per the regulations. 27. Liaise with the insurance representative or roving doctor for urgent or high-priority resubmissions. 28. Confirm acknowledgment of resubmitted cases in both HIS and payer portals. 29. Identify root causes for all rejections and document corrective recommendations. 30. Distinguish between avoidable and non-avoidable rejections during end-of-day analysis. 31. Submit a daily rejection summary to the Preauthorization Manager, covering: - Total rejections received - Avoidable vs non-avoidable ratio - High-value or repetitive rejection patterns - Breakdown by payer, physician, and service category 32. Recommend corrective actions such as MDS checklist updates, justification templates, or focused physician sessions. 33. Collaborate with Fakeeh Tech to improve HIS alerts (e.g., auto-flagging incomplete documentation or incorrect scheme linkage). 34. Participate in weekly Preauthorization Group performance meetings to present rejection trends and lessons learned. 35. Ensure complete transparency of all rejection cases to the Preauthorization Manager and Group Preauthorization leadership. 36. Support the preparation of a Weekly Rejection Dashboard, including: - Total rejection count - Avoidable vs non-avoidable percentage - Average approval turnaround time - Top 10 contributing services, physicians, or payers 37. Highlight immediate corrective actions taken and propose follow-up actions for recurring issues. 38. Uphold professional communication standards and maintain formal documentation of all internal and external correspondences. 39. Ensure continuous compliance with CHI, NPHIES, and contractual payer regulations in every stage of preauthorization and rejection management. 40. Report any non-compliance or process deviation to the Preauthorization Manager for immediate rectification and inclusion in preauthorization Group review. 41. Other duties as assigned within the scope of responsibility and requirements of the job. Experience: 3–5 years clinical practice, with at least 2 years in preauthorization/insurance or utilization management Education: Bachelor’s degree in medicine and surgery, Pharmacy, Dental or related field. Language: Excellent command of oral and written English and Arabic. Licenses / Certifications: Preferred license for practice as per the regional health regulatory authority e.g. (SCFHS / DHA).