Medical Officer - 20 Aug - Preauth- chennai Location (India)

Job Description-Pre-authorization Job Purpose To evaluate and adjudicate pre-authorization requests by reviewing medical details, policy terms, and insurer concurrence, ensuring accurate and timely approvals that contribute to effective processing and customer satisfaction. Principal Accountabilities 1. Process pre-authorization requests: Ensure timely and accurate adjudication (approval, rejection, or shortfall) - compliance with policy terms. 2. Review and validate medical details: Check system entries and documents - maintain accuracy and reduce errors. 3. Refer cases requiring specialist input: Escalate package deviations or complex cases -ensure appropriate medical decision-making. 4. Coordinate with insurers: Obtain concurrence for approvals - smooth case closure and in line with Insurer guidelines. 5. Respond to medical queries from hospitals/customers: Provide explicit communication - enhance customer experience. 6. Follow internal guidelines and regulatory standards: Maintain compliance - minimize audit observations. Reporting Structure: Reports To: Floor Manager Pre-Auth Major Challenges - Managing high volumes of pre-auth requests within defined TAT. - Managing accuracy with speed in decision-making. - Handling escalations and complex medical cases effectively. - Query Management with hospitals, insurers, and internal teams for quick resolutions. Decisions - Independent: Adjudication of standard pre-authorization cases as per policy terms. - With Approval: Escalations requiring specialist opinion, insurer concurrence, or deviations from package norms. Interactions Internal: Pre-Auth Team, Case Management, CRM team. External: - Hospitals through Query (for discharge summaries, clarifications, and missing documents). - Insurers (for concurrence and escalations). Qualifications & Experience - Education: Graduates -BHMS/BAMS/BDS - Experience: - Fresher medical graduates can apply. - Prior experience in Pre-Authorization in a TPA or HealthTech setup preferred. - Exposure to authorization processes is an added advantage. Other requirements: - Strong medical knowledge with willingness to work in a non-clinical process. - Prior experience in pre-authorization or claims (preferred). - Flexible to work in shifts and from office (no WFH). - Prior HealthTech / TPA experience is an advantage. .