-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.
Exposure to authorization processes is an added advantage.

Other requirements:
Robust medical knowledge with willingness to work in a non-clinical process.
Prior experience in pre-authorization or claims (preferred).
Adaptable to work in shifts and from office (no WFH).
Prior HealthTech / TPA experience is an advantage.

📌 Medical Officer 20 Aug Preauth Chennai Location
🏢 Vidal Health Insurance TPA
📍 Chennai