Medical Approval Officer📣 إعلان

About the Role

Walaa Cooperative Insurance Co. is seeking a Medical Approval Officer to join their team in the Eastern region. This full-time role involves evaluating and processing pre-authorization requests for medical services, ensuring compliance with company policies, insurance guidelines, and medical necessity criteria. The officer will also manage case management for in-patient admissions to ensure efficient resource utilization and high-quality patient care.

Key Responsibilities

• Verify eligibility and coverage for insured members and evaluate requests for medical services, diagnostics, treatments, procedures, and hospital admissions.
• Approve or deny requests based on medical necessity, policy limits, and established guidelines, including assessing pre-existing conditions and undeclared medical history.
• Communicate authorization decisions promptly to healthcare providers and policyholders, ensuring adherence to turnaround time (TAT) requirements.
• Monitor utilization rates to identify and report signs of fraud, waste, abuse (FWA), or suspicious patterns.
• Manage inpatient admissions, coordinate care plans with providers and patients, and arrange for second medical opinions or roving doctor visits when necessary.
• Accurately document all decisions in the company's system and maintain confidentiality of medical and insurance records.
• Manage queries from providers, insurance companies, and insured members, and provide medical guidance to the Claims Department.
• Generate regular reports on pre-authorization activities and contribute to achieving cost efficiency expectations.
• Respond to inbound and outbound calls, emails, and manage complaints to ensure customer satisfaction.

Qualifications and Experience

• Bachelor’s degree in medicine, pharmacy, or a related healthcare field. Certification in healthcare management or insurance is a plus.
• 2-5 years of experience in medical pre-authorization, claims processing, or case management within a health insurance or healthcare provider environment.
• Familiarity with health insurance industry practices, policies, and regulations.

Required Skills

• Medical Knowledge: Proficiency in medical terminology, diagnostics, clinical procedures, treatment protocols, and ICD/CPT coding systems.
• Analytical and Decision-Making: Ability to assess medical requests critically and make sound authorization decisions with strong attention to detail.
• Communication: Excellent verbal and written communication skills. Multilingual proficiency in Arabic and English is mandatory.
• Technical: Proficiency in NPHIES (National Platform for Health Information Exchange Systems) is mandatory. Proficiency in CRM and other healthcare IT systems, along with advanced MS Office skills (Word, Excel, PowerPoint).
• Customer Focus: A patient-centric approach and ability to manage challenging situations professionally and empathetically.
• Time Management: Proven ability to handle high volumes of requests efficiently and meet deadlines.
• Teamwork and Problem-Solving: Ability to collaborate effectively and resolve pre-authorization issues with professionalism and accuracy.

Compliance and Performance

The Medical Approval Officer must stay updated on medical advancements, CCHI Unified Policy, CHI Implementing Regulations, and relevant Insurance Authority (IA) circulars. Compliance with all health insurance industry standards, including HIPAA or equivalent regional guidelines, is essential. The role requires meeting or exceeding key performance indicators (KPIs) such as turnaround time, authorization accuracy, pre-existing condition detection rate, rejection justification quality, and escalation handling efficiency.

Application Process

Candidates who meet the above qualifications and are seeking a challenging role in medical approvals are encouraged to apply. Salary details will be discussed during the interview process.