Approval Specialist

Fakeeh Care Group; Medina; On-site; SAR 180,000 - 320,000; Full time

Job summary

Fakeeh Care Group in Medina, Saudi Arabia seeks a physician-led Utilization Management professional to review medical documentation, assess medical necessity, and decide on approvals or denials. The role requires collaboration with physicians, nurses, and healthcare teams to optimize patient care while controlling costs.

The candidate will analyze clinical data, stay abreast of guidelines, and contribute to process improvements and training across the department.

Responsibilities

• Reviews medical documentation to evaluate medical necessity and appropriateness of requested treatments, procedures, medications, or services.
• Analyzes clinical data to ensure that requested treatments align with established medical guidelines, protocols, and standards of care.
• Makes decisions regarding the approval or denial of requested medical services, treatments, or procedures.
• Communicates with healthcare providers, including physicians, nurses, and other medical professionals, to gather additional information, clarify clinical details, or discuss treatment options.
• Provides guidance and recommendations to healthcare providers regarding alternative treatment options, utilization management strategies, or ways to optimize patient care while controlling costs.
• Ensures accurate and thorough documentation of the approval process, including reasons for approval or denial, in accordance with regulatory requirements and organizational policies.
• Works closely with utilization management teams to streamline processes, address complex cases, and implement best practices for medical review and authorization.
• Stays informed about advancements in medical research, technology, and treatment modalities to enhance ability to make evidence-based decisions and provide informed clinical guidance.
• Contributes to quality improvement initiatives by identifying trends, opportunities for process improvement, and areas for enhanced clinical oversight or education. Identifies, analyzes, and researches frequent root causes of denials and develops corrective action plans for resolution of denials.
• Ensures compliance with relevant regulatory standards from government agencies and healthcare payer organizations.
• Provides education and training to healthcare providers, staff members, or colleagues on topics related to utilization management, medical necessity criteria, and documentation requirements.
• Participates in peer review activities to evaluate the quality,appropriateness, and outcomes of healthcare services provided, and to identify opportunities for performance improvement.
• Analyzes denial data and leads denial recovery efforts, ensuring improvement of claims processes.

Job description

1. Reviews medical documentation to evaluate medical necessity and appropriateness of requested treatments, procedures, medications, or services.
2. 2. Analyzes clinical data to ensure that requested treatments align with established medical guidelines, protocols, and standards of care.
3. 3. Makes decisions regarding the approval or denial of requested medical services, treatments, or procedures.
4. 4. Communicates with healthcare providers, including physicians, nurses, and other medical professionals, to gather additional information, clarify clinical details, or discuss treatment options.
5. 5. Provides guidance and recommendations to healthcare providers regarding alternative treatment options, utilization management strategies, or ways to optimize patient care while controlling costs.
6. 6. Ensures accurate and thorough documentation of the approval process, including reasons for approval or denial, in accordance with regulatory requirements and organizational policies.
7. 7. Works closely with utilization management teams to streamline processes, address complex cases, and implement best practices for medical review and authorization.
8. 8. Stays informed about advancements in medical research, technology, and treatment modalities to enhance ability to make evidence-based decisions and provide informed clinical guidance.
9. 9. Contributes to quality improvement initiatives by identifying trends, opportunities for process improvement, and areas for enhanced clinical oversight or education. Identifies, analyzes, and researches frequent root causes of denials and develops corrective action plans for resolution of denials.
10. 10. Ensures compliance with relevant regulatory standards from government agencies and healthcare payer organizations.
11. 11. Provides education and training to healthcare providers, staff members, or colleagues on topics related to utilization management, medical necessity criteria, and documentation requirements.
12. 12. Participates in peer review activities to evaluate the quality,appropriateness, and outcomes of healthcare services provided, and to identify opportunities for performance improvement.
13. 13. Analyzes denial data and leads denial recovery efforts, ensuring improvement of claims processes.