Approval Specialist / Senior Approval Specialist

Job Purpose:To ensure timely, accurate, and compliant processing of all medical preauthorization requests for inpatient, outpatient, ER, pharmacy, and ancillary services, safeguards hospital revenue by acting as a clinical and regulatory gatekeeper, ensuring medical necessity and entitlement in line with CHI regulations, NPHIES protocols, and payer-specific guidelines, supporting operational efficiency by reducing payer denials and avoiding financial leakage. 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, avoidable vs non-avoidable ratio, high-value or repetitive rejection patterns, and 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, and 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. Skills and Abilities: • Strong knowledge of CHI laws, preauthorization policies, and payer protocols. • Clinical judgment and ability to assess medical necessity. • High attention to detail and ability to manage high-volume requests under time constraints. • Strong communication, negotiation, and documentation skills. 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).