Associate, Preauthorization

Job Purpose:The job holder will be responsible for medical audit, PAR administration, control of fraud / abuse and assurance of customer service.Receive intimation from Provider through over regulatory portal/e-mail (non-network providers) along with relevant medical reports.Key Accountabilities:Coordinate with providers for case management and cost control.Ensure appropriate handling of the customer queries and concerns and achieving FTR.Ensure adherence to agreed SLAs for OP/IP Adjudications.Address client/broker and provider queries.Escalate customer issues and concerns where the timely resolution is not being achieved in light of the laid out policy and turn around time.Assist in the running of the PAR unit on a daily 24/7 basis.Ensure adherence to unit KPIs and internal and external SLAs.Assist in implementation of medical pre-approval processes and regulatory guidelines.Conduct onsite visits for audit of suspected cases of fraudulent practice by providers and highlight to FWA and Network team.Review and audit medical approvals and conclude pending approvals.Ensure implementation and maintenance of relevant management information systems, quality controls and SOPs.Qualifications:Medical degree or relevant clinical qualification with strong exposure to health insurance operations.Proven experience in medical auditing, pre-authorization (PAR), claims adjudication, and fraud/waste/abuse (FWA) control.Solid understanding of healthcare systems, insurance policies, and regulatory requirements.Strong decision-making ability with demonstrated capability to assess and authorize eligible medical cases.Excellent communication skills in English (written and verbal); Arabic language skills are an advantage.Proficient in IT systems, including MS Office Suite, healthcare claims management systems, and MIS reporting tools.Knowledge of medical coding standards (e.g., ICD, CPT) is highly desirable.Experience in business process improvement, including process mapping, workflow documentation, and optimization initiatives.Familiarity with quality improvement methodologies such as Lean, Six Sigma, or similar frameworks.Ability to manage multiple priorities in a 24/7 operational environment while ensuring adherence to SLAs, KPIs, and regulatory guidelines.