Health Preauthorization Specialist - Payer Operations

The Health Preauthorization Specialist is responsible for reviewing, processing, and adjudicating preauthorization requests received from TPAs in accordance with policy coverage, clinical guidelines, regulatory requirements, and service-level agreements. The role ensures that medically necessary services are appropriately authorised while maintaining member satisfaction, cost management, and compliance standards.Key ResponsibilitiesReceive and review preauthorization requests submitted by TPA's.Verify member eligibility, benefits, policy coverage, and authorization requirements.Evaluate requests against policies, clinical guidelines, medical necessity criteria, and contractual agreements.Coordinate with Medical Directors, clinicians, and case management teams for clinical reviews when required.Approve, modify, or deny authorization requests based on established guidelines.Communicate authorization decisions to TPA's and stakeholders within defined turnaround times.Request and review additional medical records or supporting documentation when necessary.Maintain accurate records of authorization decisions and supporting rationale in the claims/authorization system.Ensure compliance with regulatory requirements, accreditation standards, and company policies.Support appeals and reconsideration processes by providing authorization documentation and case history.Monitor authorization queues and ensure adherence to operational SLAs.Identify trends in authorization requests, denials, and provider inquiries for process improvement initiatives.Collaborate with Claims, Provider Relations, Utilization Management, Case Management, and Customer Service teams.Pre-requisiteMBBS / MD or equivalent medical degree recognized by the relevant health authority.3–7 years of clinical practice and/or health insurance claims management experience.Experience in preauthorization, utilization management, medical claims review, or managed care preferred.Knowledge of medical terminology, disease conditions, and treatment protocols.Familiarity with ICD-10, CPT, HCPCS, and DRG coding systems.Strong analytical, communication, and decision-making skillsFamiliarity with health insurance regulations and healthcare reimbursement processes.A physician with strong experience in the UAE health insurance claims process, possessing a comprehensive understanding of DOH, DHA, and MOHAP regulations.