مدقق طبي

<p>Position Title: Pre-Authorization Officer</p>
<p>Line of Business / Department: Approvals Team</p>
<p>Location: Oman</p>
<p>Reporting To: Medical Board Lead</p>
<p>Direct Reports: Nil</p>
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<p>Role Summary</p>
<p>The Pre-Authorization Officer will be responsible for evaluating incoming medical pre-authorization requests from healthcare providers. The role involves reviewing clinical documentation, applying insurance policy terms, and adjudicating requests based on medical necessity, internal guidelines, and regulatory requirements. The officer will work closely with hospitals, healthcare providers, and internal teams to ensure timely and accurate decisions.</p>
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<p>Key Responsibilities</p>
<p>Review pre-authorization requests across services including IP, OP, Pharmacy, Lab, Radiology, Dental, Optical, and Maternity.</p>
<p>Assess clinical documentation for completeness, relevance, and accuracy.</p>
<p>Apply insurance policy terms and medical necessity guidelines to approve, partially approve, or deny requests.</p>
<p>Verify alignment between diagnosis (ICD-10) and procedures (CPT / OSL / ODL / HCPCS).</p>
<p>Review supporting documents such as invoices, discharge summaries, medical reports, prescriptions, and diagnostic results.</p>
<p>Validate provider eligibility, benefit limits, policy exclusions, and co-payment structures (Patient Share).</p>
<p>Process requests within platforms such as TOSHFA and PBM in accordance with SOPs and regulatory requirements.</p>
<p>Identify and escalate suspicious or potentially fraudulent requests to the FWA team.</p>
<p>Document decisions with appropriate clinical and policy-based justifications in the pre-authorization system.</p>
<p>Communicate with healthcare providers to obtain additional information or clarifications when required.</p>
<p>Respond to queries from internal teams and external stakeholders regarding disputed or pending pre-authorization requests.</p>
<p>Ensure compliance with regulatory turnaround times (e.g., 30-minute TAT for OP approvals).</p>
<p>Participate in internal audits, quality checks, and training sessions.</p>
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<p>Knowledge, Skills &amp; Competencies</p>
<p>Mandatory Qualifications:</p>
<p>MBBS / BDS / Nursing</p>
<p>OR</p>
<p>B.Pharm / M.Pharm</p>
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<p>Additional Skills:</p>
<p>Knowledge of medical coding is an advantage.</p>
<p>Familiarity with health insurance operations and clinical documentation review.</p>
<p>Strong analytical and decision-making skills.</p>
<p>Good communication and coordination abilities.</p>
<p>Ability to work in a fast-paced approvals environment while maintaining regulatory compliance.</p>
<p>Career Progression</p>
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<p>Potential career progression includes advancement to Team Leader – Approvals Team.</p>
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<p>How to Apply</p>
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<p>Interested candidates are invited to submit their CV via email.</p>
<p>📧 Email: nadrass@livainsurance.com</p>
<p>📞 Phone: 71942697</p>
<p>Contact Person:</p>
<p>Recruitment Specialist</p>
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