Certification Officer

SUMMARY: The Senior Precertification Officer is responsible for obtaining prior authorizations for all procedural orders by successfully completing the authorization process with all commercial payers with high efficiency and within the agreed turnaround time to maintain the team KPIs.

MAIN TASKS:

• Assesses approval of medical approvals as well as policy use.
• Check particular treatment plan is necessary for the patient.
• Inputs verbal and written claims approvals regularly.
• Decide approvals as per policy conditions.
• Assess high-cost claims and provide decisions on high-cost and complicated cases.
• Provide clear feedback on queries from call Centre team.
• Provides clients an understanding of any declined medical claims.
• Coordinates workflow & meet deadlines.
• Evaluate claims concerning eligibility.
• Meet daily Precertification productivity target according to claims type/tenure
• Adjudicate Outpatient Precertification on first-in-first-out basis.
• Maintain Productivity TAT of 85% in 10 minutes and 98% within 1st hour and immediate emergency/ VIP
• Adherences 100% to Schedule and Punctuality.
• Decision-Making Responsibility
• Evaluate the High cost claims with efficacy and quantity to meet the daily target for the team, giving the approval for the medical condition according to the guidelines and within the policy term and condition, taking into consideration the market practice, with high liability for the invalid rejection and the customer satisfaction
• Assist the new juniors for the training and provide the feedback
• Maintain the updated guidelines for the workflow
  
  

MINIMUM REQUIREMENTS:

• Bachelors of Pharmacy,
• 4+ years Medical Practical Experience (reputable insurance provider, broker or a TPA experience a plus).
• Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.