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Clinical Approval Specialist

beBeeMedicalPreApproverThane, Maharashtra, India

19 hours ago

Job description

Medical Pre-Approval Specialist Job Description :

Job Purpose

Reputable insurance companies are seeking qualified professionals to join their medical pre-approval teams. The role involves evaluating pre-approval requests for medical procedures and treatments, ensuring they meet clinical standards and adhere to the table of benefits and health protocols.

Key Responsibilities :

Evaluating and adjudicating medical pre-approval requests based on clinical necessity
Analyzing clinical documents and patient history to determine the appropriateness of proposed treatments
Communicating with healthcare providers to clarify and obtain additional documentation when required
Providing clinical recommendations based on established medical guidelines and best practices
Maintaining strict adherence to insurance regulations, internal protocols, and medical tables of benefits
Identifying and addressing pre-approval trends from medical providers
Ensuring fair and evidence-based dispute resolution related to medical pre-approvals

Required Skills and Qualifications :

Education

Bachelor's degree in health science, pharmacy, physiotherapy, nursing, or dentistry

Experience

Minimum 2 years of relevant experience in a medical-related field or pre-approval function

Key Skills :

Solid understanding of medical treatments, procedures, and terminology

Ability to critically assess medical documentation to support informed decision-making

Excellent bilingual verbal and written communication skills for effective collaboration with healthcare providers and team members

High accuracy in evaluating claims and ensuring adherence to policies

Proficient in managing complex or ambiguous cases using sound clinical judgment

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Clinical Specialist • Thane, Maharashtra, India

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