Medical Pre-Authorization & Case Management Specialist

Walaa Cooperative Insurance Co.; Eastern Province; On-site; SAR 120,000 - 180,000; Full time

Job summary

Walaa Cooperative Insurance Co. is seeking a Medical Pre-Authorization Officer to assess and process pre-authorization requests for medical services, ensuring compliance with policies and medical necessity criteria.

You will manage in-patient case management and coordinate with providers and members to optimize care delivery. The role requires strong knowledge of ICD/CPT coding, health insurance processes, and NPHIES; you will communicate decisions professionally and maintain strict

Qualifications

• Bachelor’s degree in medicine, pharmacy or related healthcare field.
• Certification in healthcare management or insurance is a plus.
• 2–5 years of experience in medical pre-authorization, claims processing, or case management within a health insurance or healthcare provider environment.
• Familiarity with health insurance industry practices, policies, and regulations.

Responsibilities

• Verify eligibility and coverage of the insured members.
• Evaluate requests for medical services, diagnostics, treatments, procedures, and hospital admissions to determine coverage eligibility and compliance with policy terms.
• Approve or deny requests based on medical necessity, policy limits, and established guidelines.
• Assess pre-existing conditions and undeclared medical history in alignment with CCHI Unified Policy and CHI Implementing Regulations, and apply appropriate coverage exclusions where applicable.
• Promptly and professionally communicate authorization decisions to healthcare providers and policyholders.
• Ensure adherence to turnaround time (TAT) requirements for all pre-authorization requests.
• Monitor utilization rates and identify early signs of fraud, waste, abuse (FWA), or suspicious patterns, including anti-selection behaviors, with the ability to report findings.
• Monitor inpatient admissions to ensure appropriate utilization of medical services and compliance with insurance policy terms.
• Liaise with healthcare providers, patients, and internal teams to coordinate care plans.
• Arrange for a Second Medical Opinion in selected cases at one of the trusted Consultants.
• Arrange for Roving doctor’s visit for on-site assessment and review of cases with certain agreed flags.
• Review discharge plans and post-discharge needs for coverage considerations.
• Accurately document all pre-authorization and case management decisions in the company's system.
• Maintain confidentiality of medical and insurance records in accordance with company policy and legal regulations.
• Generate regular reports on pre-authorization activities, approvals, and denials for internal review.
• Stay updated on medical coding (ICD, CPT), medical advancements, CCHI Unified Policy, CHI Implementing Regulations, and relevant Insurance Authority (IA) circulars and guidelines.
• Maintain confidentiality and comply with all health insurance industry standards, including HIPAA or equivalent regional guidelines.

Skills

Medical knowledge

Analytical and decision-making

Communication skills

Multilingual proficiency: Arabic &

Time management

Teamwork

Problem-solving

Education

Bachelor’s degree in medicine, pharmacy or related healthcare field

Certification in healthcare management or insurance is a plus

Tools

NPHIES

CRM

MS Office

Job description

Walaa Cooperative Insurance Co. is seeking a Medical Pre-Authorization Officer to assess and process pre-authorization requests for medical services, ensuring compliance with policies and medical necessity criteria.

You will manage in-patient case management and coordinate with providers and members to optimize care delivery. The role requires strong knowledge of ICD/CPT coding, health insurance processes, and NPHIES; you will communicate decisions professionally and maintain strict