Medical Pre-Approval Senior Specialist

Who Are we?

Al Etihad Cooperative Insurance Company is a public joint-stock company established in the Kingdom of Saudi Arabia under a decision from the Council of Ministers and a royal decree as a cooperative insurance company. The company’s paid-up capital is 500 million Saudi Riyals. The company is an extension of United Insurance Company, which was founded in the Kingdom of Bahrain in 1983 as a foreign company to conduct insurance operations in Saudi Arabia. In 2008, the company was listed for public subscription and was registered in the Saudi Stock Exchange (Tadawul) under the symbol 8170.

The company is subject to the supervision and regulation of the Saudi Insurance Authority and is licensed to operate in all types of insurance, including general insurance, medical insurance, motor insurance, and protection & savings insurance.

The company’s experience and commitment to serving its customers have made United one of the pioneers in the insurance industry in the Kingdom. The company also has a wide network of offices and regional outlets to ensure proximity to its customers across the Kingdom. Additionally, the company has a dedicated team that strives to deliver the highest level of service to its clients.

Years of experience:

• 3-6 years.

Degree:

• Bachelor’s degree in general medicine, Medicine and Surgery.

Language:

• Excellent English language.

Main objective of the position:

Support the efficient and effective processing of medical approvals through detailed precertification assessments, verifying the medical necessity and eligibility of planned treatments, surgeries, and diagnostic procedures to facilitate timely and accurate healthcare service delivery.

Knowledge and expertise:

1. Efficiently respond to and manage routine daily precertification requests, ensuring compliance with turnaround times (TAT) and service level agreements (SLA).
2. Assess medical documentation and requests to determine the necessity and appropriateness of proposed medical procedures and management plans.
3. Utilize established guidelines and protocols to make well-informed approval decisions.
4. Achieve daily productivity targets and maintain required TAT for processing approvals.
5. Keep updated on changes in medical procedures, insurance policies, and industry regulations to enhance the quality of approval decisions and continuously improve the approval process.
6. Participate in routine daily operations, including precertification, handling CHI complaints, and collaborating with other departments on related work requirements.
7. Implement and adhere to cost containment strategies and controls in line with agreed-upon policies and procedures.
8. Report any suspicious activities observed from hospitals or insured individuals and alert the appropriate parties about potential fraud cases.
9. Respond to inquiries from healthcare providers, clients, Customer Care, and call center teams via calls and emails in a timely and efficient manner.
10. Foster teamwork and collaborate effectively with team members and other departments to enhance operational efficiency.
11. Analyze data to identify trends and areas for improvement and provide strategic recommendations to the department head.
12. Demonstrate punctuality with regular and on-time attendance, setting a standard for professional discipline.