Job Description-Pre-authorization
Job Purpose
To evaluate and adjudicate pre-authorization requests by reviewing medical details, policy terms, and insurer concurrence, ensuring accurate and timely approvals that contribute to effective processing and customer satisfaction.
Principal Accountabilities
- Process pre-authorization requests: Ensure timely and accurate adjudication (approval, rejection, or shortfall) - compliance with policy terms.
- Review and validate medical details: Check system entries and documents - maintain accuracy and reduce errors.
- Refer cases requiring specialist input: Escalate package deviations or complex cases -ensure appropriate medical decision-making.
- Coordinate with insurers: Obtain concurrence for approvals - smooth case closure and in line with Insurer guidelines.
- Respond to medical queries from hospitals/customers: Provide transparent communication - enhance customer experience.
- Follow internal guidelines and regulatory standards: Maintain compliance - minimize audit observations.

Reporting Structure:
Reports To: Floor Manager – Pre-Auth




Major Challenges
- Managing high volumes of pre-auth requests within defined TAT.
- Managing accuracy with speed in decision-making.
- Handling escalations and complex medical cases effectively.
- Query Management with hospitals, insurers, and internal teams for quick resolutions.

Decisions
- Independent: Adjudication of standard pre-authorization cases as per policy terms.
- With Approval: Escalations requiring specialist opinion, insurer concurrence, or deviations from package norms.

Interactions
Internal: Pre-Auth Team, Case Management, CRM team.
External:
- Hospitals through Query (for discharge summaries, clarifications, and missing documents).
- Insurers (for concurrence and escalations).

Qualifications & Experience
- Education: Graduates -BHMS/BAMS/BDS
- Experience:
- Fresher medical graduates can apply.
- Prior experience in Pre-Authorization in a TPA or HealthTech setup preferred.
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📌 Medical Officer (Chennai)
🏢 Vidal Health Insurance TPA
📍 Chennai