أخصائي الموافقات الطبية / أخصائي أول الموافقات الطبية

Job Purpose:
To ensure timely, accurate, and compliant processing of all medical preauthorization requests for inpatient, outpatient, ER, pharmacy, and ancillary services, safeguards hospital revenue by acting as a clinical and regulatory gatekeeper, ensuring medical necessity and entitlement in line with CHI regulations, NPHIES protocols, and payer-specific guidelines, supporting operational efficiency by reducing payer denials and avoiding financial leakage.

Key Responsibilities and Duties:

• Ensure full adherence to the Council of Health Insurance (CHI) Preauthorization Policy, NPHIES standards, and individual payer coverage protocols.
• Prevent unauthorized, uncovered, or non-contracted services from being initiated.
• Support the implementation and compliance of NPHIES downtime contingency procedures.
• Verify the completeness of clinical documentation and utilization of the Minimum Data Set (MDS) for every request.
• Review the 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 prior to 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 to follow up on pending or queried cases in real time.
• 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 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 the 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, 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 (e.g., 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.
• Other duties as assigned within the scope of responsibility and requirements of the job.

Requirements

Skills and Abilities:

• Strong knowledge of CHI laws, preauthorization policies, and payer protocols.
• Clinical judgment and ability to assess medical necessity.
• High attention to detail and ability to manage high-volume requests under time constraints.
• Strong communication, negotiation, and documentation skills.

Experience:

• 3–5 years clinical practice, with at least 2 years in preauthorization/insurance or utilization management.

Education:

• Bachelor's degree in medicine and surgery, Pharmacy, Dental or related field.

Language:

• Excellent command of oral and written English and Arabic.

Licenses / Certifications:

• Preferred license for practice as per the regional health regulatory authority e.g. (SCFHS / DHA).