Qureos Mentor

Fakeeh Care Group

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 Description
 
 
 
 Key Responsibilities and Duties:
 
 
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 Ensure full adherence to the Council of Health Insurance (CHI) Preauthorization Policy, NPHIES standards, and
 
 
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 individual payer coverage protocols.
 
 
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 Prevent unauthorized, uncovered, or non-contracted services from being initiated.
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 Support the implementation and compliance of NPHIES downtime contingency procedures.
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 Verify the completeness of clinical documentation and utilization of the Minimum Data Set (MDS) for every
 
 
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 request.
 
 
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 Review the treating physician&rsquo;s progress notes, diagnostics, prescriptions, and clinical justifications for
 
 
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 accuracy and adequacy.
 
 
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 Validate medical necessity in alignment with evidence-based guidelines, CHI standards, and payer criteria.
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 Ensure accurate clinical coding and scheme linkage to prevent claim denials.
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 Escalate incomplete or inaccurate documentation for correction prior to submission.
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 Liaise with treating physicians, nurses, and roving doctors to secure approvals and clarify case details.
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 Communicate approvals, denials, and payer queries within CHI-mandated timelines.
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 Respond to payer or insurer queries within 30 minutes of receipt.
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 Escalate urgent or high-priority cases (ER, ICU, Oncology, or high-cost procedures) immediately to the
 
 
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 Preauthorization Manager.
 
 
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 Monitor HIS/NPHIES queues to follow up on pending or queried cases in real time.
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 Maintain updated approval status in both HIS and the patient&rsquo;s record.
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 Ensure 100% completion of approvals for all discharges within the same day.
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 Confirm that same-day discharge and high-cost cases are fully approved prior to billing.
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 Document all approvals, denials, and payer communications in the patient&rsquo;s medical record.
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 Participate in the daily discharge reconciliation process and report pending approvals to the Preauthorization
 
 
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 Manager.
 
 
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 Review all preauthorization rejections received through NPHIES, payer portals, or HIS at least twice per shift.
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 Categorize rejections based on cause (missing justification, duplication, non-covered service, exceeded limit,
 
 
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 coding error, or late submission).
 
 
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 Record all rejections in the Rejection Tracker Log with patient MRN, preauthorization number, payer,
 
 
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 rejection reason, and physician name.
 
 
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 Coordinate with the Preauthorization Supervisor to ensure each rejection is reviewed and analyzed within the
 
 
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 assigned TAT.
 
 
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 Engage directly with the treating physician for clarification or missing documentation related to rejected
 
 
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 cases.
 
 
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 Provide constructive feedback and guidance to physicians to avoid recurrence, referencing insurer
 
 
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 preauthorization protocols, CHI guidelines and NPHIES dataset requirements.
 
 
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 Conduct same-day briefings for rejections involving high-cost services.
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 Resubmit corrected documentation within the payer&rsquo;s appeal window as per the regulations.
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 Liaise with the insurance representative or roving doctor for urgent or high-priority resubmissions.
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 Confirm acknowledgment of resubmitted cases in both HIS and payer portals.
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 Identify root causes for all rejections and document corrective recommendations.
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 Distinguish between avoidable and non-avoidable rejections during end-of-day analysis.
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 Submit a daily rejection summary to the Preauthorization Manager, covering:
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 Total rejections received
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 Avoidable vs non-avoidable ratio
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 High-value or repetitive rejection patterns
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 Breakdown by payer, physician, and service category
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 Recommend corrective actions such as MDS checklist updates, justification templates, or focused physician
 
 
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 sessions.
 
 
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 Collaborate with Fakeeh Tech to improve HIS alerts (e.g., auto-flagging incomplete documentation or
 
 
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 incorrect scheme linkage).
 
 
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 Participate in weekly Preauthorization Group performance meetings to present rejection trends and lessons
 
 
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 learned.
 
 
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 Ensure complete transparency of all rejection cases to the Preauthorization Manager and Group
 
 
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 Preauthorization leadership.
 
 
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 Support the preparation of a Weekly Rejection Dashboard, including:
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 Total rejection count
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 Avoidable vs non-avoidable percentage
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 Average approval turnaround time
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 Top 10 contributing services, physicians, or payers
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 Highlight immediate corrective actions taken and propose follow-up actions for recurring issues.
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 Uphold professional communication standards and maintain formal documentation of all internal and
 
 
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 external correspondences.
 
 
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 Ensure continuous compliance with CHI, NPHIES, and contractual payer regulations in every stage of
 
 
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 preauthorization and rejection management.
 
 
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 Report any non-compliance or process deviation to the Preauthorization Manager for immediate rectification
 
 
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 and inclusion in preauthorization Group review.
 
 
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 Other duties as assigned within the scope of responsibility and requirements of the job.
 
 
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 Requirements
 
 
 
 Experience: 3&ndash;5 years clinical practice, with at least 2 years in preauthorization/insurance or
 
 
 utilization management
 
 
 Education: Bachelor&rsquo;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).
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Approval Specialist

Join Fakeeh Care Group and explore 1   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

Fakeeh Care Group

About Company

Approval Specialist