• Maintain accountability for position duties as determined by the Operation Director/Senior Manager, Call Center
• Actively participate in departmental performance improvement initiatives and actively comply with established quality indicators
• Actively collaborate with the CMO and Medical Network Specialist to optimize resource utilization (including minimizing unnecessary costs)
• Comply with departmental policies and procedures for case management
• Actively participate in the development and revision of department specific policies as indicated
• Perform daily responsibilities that include:
• Final approval of all medical evacuations evidenced by signing off on the medical necessity of each such evacuation in conjunction with the on-duty Supervisor
• Monitor medical cases by telephone contact with treating medical providers and review of medical reports
• Review medical cases to determine compatibility of medical condition and treatment
• Recommend and review travel requirements in conjunction with the treating physician
• Thorough case documentation
• Review of claims-related cases as requested
• Participate in Medical Escorts/Crisis Response
• Leadership / Teamwork:
• To work with others and promote a collaborative environment that facilitates growth of other team members and colleagues
• Interact with all personnel in a professional and appropriate manner in order to achieve the objectives of the department and company
• Evaluate and process inpatient and emergency prior authorization requests in accordance with respective policies schedule of benefits
Evaluate the medical need for the requested service according to the medical data provided and accurately code the service description codes stated on the prior authorization requests, according to accepted medical coding rules, medical guidelines and policy’s schedule of benefits.
• Achieve the proper capturing of the data on the system with a focus on accuracy, efficiency, ensuring that business decisions and processes are documented in a professional way.
• Constantly work on improving the turnaround time and relevant functional and personal competencies
• Ensure that the medical ethics are respected at all times during the fulfilling of the tasks
• Report suspected cases of fraud and/or abuse of the healthcare providers to respective medical authorization supervisor
• Handle changes in the work load flow from healthcare providers in terms of time, quantity and type of prior authorization requests received with a clear focus on the both quality and set target.
• Process high cost pre-authorization request in line with the high cost authority matrix
• Support the company’s decisions keeping the company professionally represented at all times
Minimum Education Level:
Bachelor's Degree/Post Graduate Diploma/Professional Degree
Minimum Years of Experience:
Technical Skills or Particular Experience:
• Required Minimum Education: Bachelor's Degree/Master Degree in medicine from recognized university.
• A valid Annual Practicing Certificate.
• At least 4 year(s) of working experience preferably with experience in insurance company/TPA/hospital.
• Computer literate and a proficient user of MS Office applications.
• Ability to multi-task and prioritize workload (E.g. incoming work, projects).
• Ability to comprehend basic correspondence.
• Strong presentation skills and experience with developing and delivering formal presentation to large groups.
Suite No.802, Level 8, Menara Amcorp, Amcorp Trade Centre, 18, Jalan Persiaran Barat, Petaling, Selangor, Malaysia
Melorita Healthcare is a Malaysian based healthcare recruitment agency. Set up over 35 years ago we are the pioneers in this business and have been providing healthcare professionals with the best jobs in locations around the world for over 3 decades. MELORITA has its headquarters in Kuala Lumpur, Malaysia and branch offices in all major cities in Malaysia including Penang, Johor Bahru, Kuching and Kota Kinabalu. Melorita continues to grow and is always looking for new opportunities to provide its clients and candidates and is committed to its vision of being a global company with world class practices.