JOB DESCRIPTION
Responsible of obtaining authorization approvals whenever needed in the below conditions:
- Daman and contracted insurance as per the policy terms and conditions.
- Non Contracted insurance by communicating guaranty of payment.
The role holder is responsible of insurance labiality and fund reallocation for the rejected services under the ABM policy along with attending patients self-pay estimation whenever needed. Job holder will also communicate efficiently with internal/external stakeholders to ensure finalizing patients authorization requests. Should be responsible to counsel self-pay patients, collect, pre-payments, and outstanding balances following established collection procedures.
RESPONSIBILITIES
- Manages to receive and adjudicate approval requests through the agreed communication channels.
- Coordinates to do initial assessment of the approval request and do the needed internal collaboration to ensure all the needed documents/data from the clinical/coding Side are complete and accurate.
- Facilitates once documents are complete communicate with the payers through the official communication channels (emails-Payers Portals, E authorization in-house system).
- Manages all correspondence with insurance companies, physicians, coding and patients in case of authorization denials to ensure clearing the insurance queries accordingly.
- Ensures logging and updating all assigned requests in the productivity tracking sheet.
- Coordinates to have a proper follow up on the pending to obtain a timely manner approvals.
- Ensures receiving and communicating approvals/GOPs internally as per the agreed process.
- Oversees that approvals/GOPs are correct and matching the requested services (DRG-CPTS- Drugs, HCPCs).
- Ensures obtaining the needed reauthorization revisions as per the regulators rules.
- Prepares and follow process escalation matrix to report delayed cases due to any external factors.
- Maintains and updates documents and insurance records such as eligibility, medical reports, treatment plan, claim amounts etc.
- Prepares reports as required on self-pay data for review by the senior management
- Documents information in the HIS and billing system completely and accurately in order to ensure that the respective patient information is updated.
- Demonstrates customer focus when interacting with internal or external stakeholders.
- Analyses documents such as medical reports and insurance regulations and providing the relevant inputs from same to the concerned parties
- Liaises with the Medical Records staff for coding and finance staff for billing purposes.
- Determines to self-pay patient lists and call patients and/or their sponsors to check their insurance status and coverages.
- Manages visits self-pay patients throughout the hospital including, Emergency Room (ER) and Inpatient locations to discuss patient responsibility, ability to pay, availability of financial assistance.
- Assures completing clearance process of current-day patients, next-day patients
- Liaises with case managers and discharging team on patient issues with insurance implications
- Develops affordable payment plans for self-pay patients.
- Gathers all relevant information required to process financial assistance request.
- Facilitates and registers Guarantee of Payment (GOP) letters; maintains a copy of the Letter and provides Approval for treatment if required.
- Maintains patient statement of account on GOP letters with limits and provides approval for treatment if required.
- Prepares updated Statement of Account re: Charity Deposits, and provides Approval for treatment if required
- Monitors and Follow-up GOP revision required with regards to wrong DOA/Facility name/Amount/Service
- Assists patients seeking assistance for outstanding claims, issuance of receipts, and Charity applications.
- Completes all necessary paperwork in a timely manner.
- Coordinates with outside resources (Red Crescent) to secure payment for medical care.
- Monitors, maintain, analyze and update the financial reports of the patients to ensure all the accounts are maintained at acceptable.
- Collects estimated liability documents from patients.
- Assists and remain in constant touch with patients, to review their insurance benefits, and provide them with alternative solutions.
- Communicates financial coverage status and applicable financial decisions with all appropriate parties: patient , family , referring clinicians
- Complies with relevant rules, regulations, policies , and procedures
- Performs other duties as assigned.
Accountabilities
- Collects and maintains estimated liabilities from patients.
- Establishes and takes charge of health insurance benefits, conditions, and requirements by making phone inquiries, and by using eligibility systems and the internet.
- Maintains patients employment details and other particulars
QUALIFICATIONS
Experience :-
Required:
- 2-4 years of relevant experience
Desired:
- Experience in a large healthcare facility
Educational Qualification: Required:
- Diploma in Accounting/Finance/Commerce or relevant field
Desired:
- Bachelors degree or equivalent in Accounting/Finance/Commerce or relevant field
ABOUT US
At SSMC, we firmly believe that the human touch is a fundamental part of care. We understand that health care is both an art and a science, running deeper than simply diagnosing and treating those who rely on us. Our SSMC Model of Care puts our patients at the forefront of our purpose and at the heart of everything we do, ensuring that the needs of our patients come first. Every one of our patients receives individualized attention from a multidisciplinary team of experts who collaborate closely to deliver trusted and compassionate care. From the very first point of contact with SSMC, to the moment patients are back home, we ensure speciality-specific care at every stage and in every interaction. As one of the largest tertiary hospitals in the UAE, SSMC provides access to specialist medical treatments and advanced diagnostics, with a commitment to becoming a Destination Medical Center in the UAE and wider region.
ABOUT THE TEAM
About Sheikh Shakhbout Medical City (SSMC)
SSMC is the largest tertiary hospital in the UAE and serves to elevate the provision of health care services in the nation under the mandate of the Abu Dhabi Economic Vision 2030.
Supported by the latest diagnostic and treatment modalities available, SSMC offers care in 44 specialties. A team of locally and internationally trained medical, clinical and admin professionals work seamlessly together, which promotes comprehensive interdisciplinary learning, allowing SSMC to become a leading hub for integrated patient-centric medical services in the region.
As the regions leading tertiary facility, SSMC has 742 patient beds, 18 operating theatres, and includes a hybrid operating room, 26-bed neonatal intensive care unit, and the UAEs largest pathology lab.
