Approval Specialist / Senior Approval Specialist

About the role

Requirements

• 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).

Responsibilities

• - 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.

Skills

• CHI preauthorization policies
• NPHIES standards
• MDS (Minimum Data Set)
• clinical documentation review
• clinical coding
• payer liaison
• claims denial Prevention
• HIS system familiarity
• payers portals (NPHIES, CHI)
• medical necessity assessment
• communication and negotiation
• time management
• English and Arabic proficiency