Approval Specialist

Description

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 received
• Avoidable vs non-avoidable ratio
• High-value or repetitive rejection patterns
• 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
• 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

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).