Associate, Preauthorization

Job Description

Job Purpose:

• The job holder will be responsible for medical audit, PAR administration, control of fraud / abuse and assurance of customer service.
• Receive intimation from Provider through over regulatory portal/e-mail (non-network providers) along with relevant medical reports.

Key Accountabilities:

• Coordinate with providers for case management and cost control.
• Ensure appropriate handling of the customer queries and concerns and achieving FTR.
• Ensure adherence to agreed SLAs for OP/IP Adjudications.
• Address client/broker and provider queries.
• Escalate customer issues and concerns where the timely resolution is not being achieved in light of the laid out policy and turn around time.
• Assist in the running of the PAR unit on a daily 24/7 basis.
• Ensure adherence to unit KPIs and internal and external SLAs.
• Assist in implementation of medical pre-approval processes and regulatory guidelines.
• Conduct onsite visits for audit of suspected cases of fraudulent practice by providers and highlight to FWA and Network team.
• Review and audit medical approvals and conclude pending approvals.
• Ensure implementation and maintenance of relevant management information systems, quality controls and SOPs.

Qualifications:

• Medical degree or relevant clinical qualification with strong exposure to health insurance operations.
• Proven experience in medical auditing, pre-authorization (PAR), claims adjudication, and fraud/waste/abuse (FWA) control.
• Solid understanding of healthcare systems, insurance policies, and regulatory requirements.
• Strong decision-making ability with demonstrated capability to assess and authorize eligible medical cases.
• Excellent communication skills in English (written and verbal); Arabic language skills are an advantage.
• Proficient in IT systems, including MS Office Suite, healthcare claims management systems, and MIS reporting tools.
• Knowledge of medical coding standards (e.g., ICD, CPT) is highly desirable.
• Experience in business process improvement, including process mapping, workflow documentation, and optimization initiatives.
• Familiarity with quality improvement methodologies such as Lean, Six Sigma, or similar frameworks.
• Ability to manage multiple priorities in a 24/7 operational environment while ensuring adherence to SLAs, KPIs, and regulatory guidelines.

Benefits found in job post

Medical insurance

Requirements added by the job poster

• 3+ years of work experience with Medical Claims Processing