Approval Specialist / Senior Approval Specialist

Approval Specialist / Senior Approval Specialist

The primary role of an Approval Specialist/Senior Approval Specialist is to ensure the timely, accurate, and compliant processing of all medical preauthorization requests for various services, safeguarding hospital revenue by acting as a clinical and regulatory gatekeeper. This involves verifying medical necessity and entitlement in line with CHI regulations, NPHIES protocols, and payer-specific guidelines, thereby supporting operational efficiency and reducing payer denials.

• Ensure full adherence to CHI Preauthorization Policy, NPHIES standards, and individual payer coverage protocols.
• Prevent unauthorized, uncovered, or non-contracted services from being initiated.
• Support NPHIES downtime contingency procedures implementation and compliance.
• Verify clinical documentation completeness and MDS utilization for every request.
• Review and 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.
• Liaise with healthcare professionals to secure approvals and clarify case details.
• Communicate approvals, denials, and payer queries within CHI-mandated timelines.
• Monitor HIS/NPHIES queues to follow up on pending or queried cases in real time.
• Review and categorize preauthorization rejections, coordinate with the Preauthorization Supervisor for review and analysis.
• Engage directly with treating physicians for clarification or missing documentation related to rejected cases.
• Identify root causes for rejections, document corrective recommendations, and submit daily rejection summaries.
• Collaborate with Fakeeh Tech to improve HIS alerts and workflows.