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Medical Officer - Specialist 1
Vidal Health Insurance TPA · Jaipur, Rajasthan, India
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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 clear 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:
- Strong medical knowledge with willingness to work in a non-clinical process.
- Prior experience in pre-authorization or claims (preferred).
- Flexible to work in shifts and from office (no WFH).
- Prior HealthTech / TPA experience is an advantage.