Approval Specialist📣 Job Ad

About the Role

Fakeeh Care Group is seeking a dedicated and detail-oriented Approval Specialist to join their team in Riyadh, Saudi Arabia. This full-time position is integral to ensuring the compliant processing of preauthorizations and the effective management of insurance claims within healthcare facilities. The Approval Specialist will play a key role in maintaining adherence to regulatory standards and payer protocols, contributing to efficient patient care and financial operations.

Key Responsibilities

• Ensure full adherence to the Council of Health Insurance (CHI) Preauthorization Policy, NPHIES standards, and individual payer coverage protocols.
• Prevent the initiation of unauthorized, uncovered, or non-contracted services.
• Support the implementation and compliance of NPHIES downtime contingency procedures.
• Verify the completeness of clinical documentation and the utilization of the Minimum Data Set (MDS) for all requests.
• Review treating physician's progress notes, diagnostics, prescriptions, and clinical justifications for accuracy and adequacy.
• Validate medical necessity in alignment with evidence-based guidelines, CHI standards, and payer criteria.
• Ensure accurate clinical coding and scheme linkage to prevent claim denials.
• Escalate incomplete or inaccurate documentation for correction before submission.
• Liaise with treating physicians, nurses, and roving doctors to secure approvals and clarify case details.
• Communicate approvals, denials, and payer queries within CHI-mandated timelines.
• Respond to payer or insurer queries within 30 minutes of receipt.
• Escalate urgent or high-priority cases (ER, ICU, Oncology, or high-cost procedures) immediately to the Preauthorization Manager.
• Monitor HIS/NPHIES queues for real-time follow-up on pending or queried cases.
• Maintain updated approval status in both HIS and the patient’s record.
• Ensure 100% completion of approvals for all discharges within the same day.
• Confirm that same-day discharge and high-cost cases are fully approved prior to billing.
• Document all approvals, denials, and payer communications in the patient’s medical record.
• Participate in the daily discharge reconciliation process and report pending approvals to the Preauthorization Manager.
• Review all preauthorization rejections received through NPHIES, payer portals, or HIS at least twice per shift.
• Categorize rejections based on cause (missing justification, duplication, non-covered service, exceeded limit, coding error, or late submission).
• Record all rejections in the Rejection Tracker Log with patient MRN, preauthorization number, payer, rejection reason, and physician name.
• Coordinate with the Preauthorization Supervisor to ensure each rejection is reviewed and analyzed within the assigned Turnaround Time (TAT).
• Engage directly with the treating physician for clarification or missing documentation related to rejected cases.
• Provide constructive feedback and guidance to physicians to avoid recurrence, referencing insurer preauthorization protocols, CHI guidelines, and NPHIES dataset requirements.
• Conduct same-day briefings for rejections involving high-cost services.
• Resubmit corrected documentation within the payer’s appeal window as per regulations.
• Liaise with the insurance representative or roving doctor for urgent or high-priority resubmissions.
• Confirm acknowledgment of resubmitted cases in both HIS and payer portals.
• Identify root causes for all rejections and document corrective recommendations.
• Distinguish between avoidable and non-avoidable rejections during end-of-day analysis.
• Submit a daily rejection summary to the Preauthorization Manager, covering total rejections received, avoidable vs non-avoidable ratio, high-value or repetitive rejection patterns, and breakdown by payer, physician, and service category.
• Recommend corrective actions such as MDS checklist updates, justification templates, or focused physician sessions.
• Collaborate with Fakeeh Tech to improve HIS alerts (*, auto-flagging incomplete documentation or incorrect scheme linkage).
• Participate in weekly Preauthorization Group performance meetings to present rejection trends and lessons learned.
• Ensure complete transparency of all rejection cases to the Preauthorization Manager and Group Preauthorization leadership.
• Support the preparation of a Weekly Rejection Dashboard, including total rejection count, avoidable vs non-avoidable percentage, average approval turnaround time, and top 10 contributing services, physicians, or payers.
• Highlight immediate corrective actions taken and propose follow-up actions for recurring issues.
• Uphold professional communication standards and maintain formal documentation of all internal and external correspondences.
• Ensure continuous compliance with CHI, NPHIES, and contractual payer regulations in every stage of preauthorization and rejection management.
• Report any non-compliance or process deviation to the Preauthorization Manager for immediate rectification and inclusion in preauthorization Group review.
• Perform other duties as assigned within the scope of responsibility and requirements of the job.

Qualifications and Requirements

• 3-5 years of experience in clinical practice, with at least 2 years specifically in preauthorization, insurance, or utilization management.
• Bachelor's degree in Medicine and Surgery, Pharmacy, Dental, or a related healthcare field.
• Excellent command of both oral and written English and Arabic languages.
• Preferred license for practice as per the regional health regulatory authority (*, SCFHS / DHA).

Required Skills

• Clinical Documentation
• Utilization Management
• Medical Necessity Validation
• Clinical Coding
• Claim Denials Prevention
• Physician Liaison
• Payer Communication
• Real-time Monitoring
• Discharge Reconciliation
• Rejection Analysis
• Root Cause Analysis
• Corrective Actions
• Performance Reporting
• Compliance
• Professional Communication

Work Environment and Details

This is a full-time position based in Riyadh, Saudi Arabia. The role operates within Fakeeh Care Group.