Responsibilities
Key Responsibilities
Coordinate all inpatient and outpatient pre-authorization requests, extensions, and undertakings with payers.
Ensure timely submission, follow-up, and approval of pre-authorizations and extensions within required turnaround times.
Liaise with insurers, brokers, patients, and internal clinical teams to provide timely communication and clarification.
Validate and manage undertakings, guarantee of payments, and financial exposures for admissions and specialized procedures.
Ensure accuracy, completeness, and compliance of documentation and medical reports required by payers.
Review service validity, membership, and benefit coverage against payer rules and clinical standards.
Maintain accurate and structured records of authorization activities, including high-value cases.
Coordinate inward and outward referrals, ensuring complete documentation and seamless continuity of care.
Monitor trends, generate reports (daily, weekly, monthly), and identify gaps for continuous improvement.
Support interdepartmental communication to enhance timely service flow and customer experience.
Conduct capacity building for staff on appropriate billing and care coordination.
Uphold compliance with regulatory, ethical, and care quality standards.
Qualifications
Qualifications & Experience
Essential
Bachelor's Degree in Nursing, Clinical Medicine, or related healthcare field.
Minimum 3 years' experience in:
Care coordination / Case management
Utilization review
Medical insurance liaison
Claims processing
Admission and discharge management
Experience working with insurers, payers, and TPAs.
Proven ability to interpret medical documentation, reports, and treatment plans.
Desirable
Certification in Case Management, Utilization Management, or Health Insurance.
Experience in referral coordination or clinical pathways.
Experience in a multi-specialty hospital environment.
Experience using HIS/EMR authorization modules.