Job Family Card - Health Operations

Review life and medical reports and doctor’s recommendation (for health care service, treatment plan, prescription drug, or durable medical equipment that is medically necessary, and health report requested for disability or death) from the appointed health care provider. Contact the results of either approval or denial of the authorization request. Ensure all prior authorization and field operations requests are dealt with promptly as per the organization's policies and procedures.

Job Family Code

IHO

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Job Roles

Card Job Role Description

Job Role

Pre-authorisation Associate

Job Family Code

IHO

Job Family

Health Operations

Responsibilities

    Handle incoming and outgoing mail and faxes tracking pre-authorisation claims.

    Follow up on pre-authorisation processes and ensure timely responses.

    Prepare pre-authorisation memos, invoices, or other reports.

    Ensure payment of services by verifying benefits with provider.

    Monitor and track patients authorisations ensuring policy validity dates.

Card Job Role Description

Job Role

Pre-authorisation Officer

Job Family Code

IHO

Job Family

Health Operations

Responsibilities

    Review medical reports and prescribed treatment to assess patients clinical condition and recommend approval/ disapproval of claim according to policy terms.

    Handle pre-authorisation requests from healthcare providers and clients.

    Monitor pre-authorisation claims frequencies and repetitions to advise on potential policy changes and related risk factors.

    Report suspected fraud cases to management and provide evidence documents.

    Monitor patients’ records and accounts and ensure that pre-authorisation information is recorded and processed.

Card Job Role Description

Job Role

Senior Pre-authorisation Specialist

Job Family Code

IHO

Job Family

Health Operations

Responsibilities

    Recommend right price to the requested service by revising updated provider packages with the organisation's medical policy.

    Review accuracy and completeness of information requested for pre-authorisation and ensure that pre-authorisation decision is appropriate.

    Receive requests for pre-authorisations and ensure that they are properly and closely monitored.

    Assist with medical necessity documentation to expedite approvals and ensure that appropriate follow-up is performed.

    Review in-patient medical file and discuss with the treating consultant to ensure efficient and timely provision of service.

Card Job Role Description

Job Role

Pre-authorisation and Field Manager

Job Family Code

IHO

Job Family

Health Operations

Responsibilities

    Develop and oversee implementation of medical policies and pre-authorisation procedures inline with the organisation's claims criteria.

    Develop and maintain network and provider relationships by ensuring accurate and timely responses to provider requests, monitoring roving doctors interaction with providers.

    Ensure only appropriate and necessary treatments are approved and align closely with the underwriting to support pricing and margins.

    Identify trends and recommend automated solution to improve speed and quality of re-authorisation response in sync with providers systems.

    Monitor pre-authorisation specialist and doctors interaction with providers and assess their performance.

Card Job Role Description

Job Role

Head of Health Operations

Job Family Code

IHO

Job Family

Health Operations

Responsibilities

    Contribute to the formulation of the overall organisation's strategy, in collaboration with others in the executive team, focusing on the organisation's health operations.

    Approve and ensure implementation of health operations policies and procedures and ensure its efficiency.

    Manage health operations and ensures its compliance to regulatory requirements as well as market standards.

    Manage and monitor health operations budget for cost efficiency.

    Manage internal and external relationships and represent the organisation in all business matters related to health operations.

    Oversee health service network and ensure renewal of best performing providers.

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