Approval Services Manager📣 Job Ad

About the Role

The National Medical Care Company (Care) is seeking a dedicated Approval Services Manager to join its team in Riyadh. This full-time role is central to achieving the strategic objectives of the sector by overseeing the comprehensive review and approval process for medical service requests. The manager ensures clinical appropriateness and strict compliance with established medical guidelines and regulatory requirements, serving as a critical link between medical providers, internal departments, and regulatory bodies.

Key Responsibilities

• Contribute to the strategic objectives of the sector by managing direct reports' performance and setting departmental goals.
• Provide guidance and direction to direct reports, ensuring their ongoing development and effective utilization of resources.
• Oversee the review and approval process for medical service requests, ensuring clinical appropriateness and adherence to medical guidelines and regulatory requirements.
• Act as a primary liaison between medical providers, internal departments, and regulatory bodies to facilitate accurate and timely decision-making on patient care approvals.
• Supervise and manage the medical pre-authorization and approval team.
• Review and assess medical service requests based on clinical guidelines, established policies, and patient medical history.
• Collaborate with physicians, case managers, and claims departments to ensure accurate evaluations.
• Ensure compliance with internal protocols, payer policies, and relevant healthcare regulations.
• Train and support staff on clinical policies, coding standards, and documentation requirements.
• Implement quality assurance processes for approval decisions and maintain high service standards.
• Resolve escalated cases and appeals in collaboration with the medical review board or medical director.
• Generate and analyze reports related to approval trends, turnaround times, and reasons for denial.
• Prepare reports for hospital administration on approval process outcomes and compliance metrics.
• Conduct regular audits and assist in implementing corrective actions as necessary.

Required Competencies

• Decision Making: Ability to leverage available information within the area of work to navigate ambiguous situations and arrive at appropriate solutions.
• Generate Ideas: Capacity to adopt new approaches to business-as-usual operations, fostering agility and moving beyond traditional methods.
• Strategic Direction: Drives external orientation and understands developments in the healthcare sector that impact strategic plans for the section or sub-department.
• Develops Talent: Takes proactive steps to build team capability by identifying learning opportunities, such as exposure to varied work areas and job enrichment through added responsibility.

Key Performance Indicators

• Approval Turnaround Time: Measuring the average time taken to process and approve new services or programs.
• Compliance Rate: Percentage of approvals that meet regulatory standards and guidelines upon initial submission.
• Audit Findings: Number of compliance issues or discrepancies identified during internal audits over a specified period.
• Stakeholder Satisfaction: Feedback scores from internal stakeholders, such as department heads and medical staff, regarding the effectiveness of the approval process and communication.

Application Process

The National Medical Care Company (Care) is committed to maintaining high standards in medical service approvals. Qualified candidates are encouraged to apply for this full-time position in Riyadh.