Role Purpose

Responsible to review and approve medical services requested by providers or customers according to medical necessity review guidelines. Will ensure customers receive the best quality care, diagnostics and treatment and avoid over or under-utilization of clinical services. Ability to review, investigate and respond to external and internal inquiries/complaints. Provide guidance to other clinical and non-clinical staff related to medical necessity.

MAJOR RESPONSIBILITIES

• Assess and process medical approvals using the company system in accordance with conditions & terms of medical policies.
• Give evidence-based advice on preauthorization and medical claims considering internationally accepted protocols and local and or regional customs and regulations. Will use Cigna coverage policy and MCG guidelines.
• Identify and refer cases to the clinical programs team for case management, disease management and other clinical services and assure quality of performance against QA standards to promote optimal service delivery. Give appropriate corrective action if necessary.
• To assist queries from providers and payers via phone calls or e-mails.
• Ensure that hospitals worldwide receive expertise advisory and all necessary documents for a plan member’s admission within the best possible terms.
• Undertaking of hospital admission approvals and declines.
• Ensure appropriate Turnaround Time is adhered to in issuing inpatient and outpatient guarantee of payment approvals.
• Seeking medical clarifications including medical reports, copies of investigation reports, etc.
• Maintain relations by communicating all necessary admission guarantee of payment decisions on a timely basis.
• Ensuring guarantee of payments undertakings are issued in line with the policy provisions. Likewise for declines, ensuring that the decisions are accurate and a correct interpretation of the policy.
• Work with the provider claims reviewers for inpatient claims and coordinating on any information noted in the inpatient claim submitted especially in cases where further information provided changes the position undertaken previously on the claim.
• Interacting with clients, brokers and clinicians as needed, to resolve problems in a manner that is legal, ethical, and consistent with the principles of the policy.
• Checking and confirming membership validity and benefits from policy documents.
• Vetting and confirming validity of the service given by the service provider in relation to the benefits covered, treatment given, adherence to provider panel rules and cost of treatment.
• Obtaining additional required information on claims from providers, brokers, or clients.
• Liaising with our eligibility section on scope of cover for various contracts.
• Training new colleagues in the team.
• You organize the in- and outflow of all incoming communication with special attention to the quality of the messages and to the response turnaround times.
• All of these tasks are performed in English or other languages. French, Portuguese or Spanish an added advantage.

YOUR PROFILE

• Medical degree or Nursing degree with healthcare/insurance experience.
• Insurance Professional qualification a plus
• Proficient in the use of Microsoft Office Suite and packages Relevant Experience
• You have 2-3 years of clinical experience preferably in a hospital setup or insurance medical management, case management, disease management programs and tools are an advantage.
• You have knowledge of utilization, cost containment services, and insurance coverage.
• You are flexible to work on shifts/varying work schedules.
• You work accurately and have ability to work under pressure and meet tight deadlines.
• You are strong in communication.
• You are service-minded.
• You have a strong sense of responsibility.
• You can easily handle procedures regarding document verification.
• You can easily work with several software applications simultaneously
• You are analytical and like taking initiative
• You handle confidential information in a discrete manner.
• You work autonomously but also enjoy working as part of a team.