وظيفة مسؤول الموافقات الطبية شاغرة لدى سايكو للتأمين بالرياض

JOB PURPOSE : Coordinate and perform the implementation of SAICO medical approval operation services

KEY RESPONSIBILITIES :

• Conduct ongoing clinical evaluation of treatment plans and return‑to‑work plans in accordance with established medical standards and protocols.
• Process and manage all medical approval transactions per shift, ensuring adherence to approved policies and coverage guidelines.
• Ensure compliance with approval Turnaround Time (TAT) as follows:
• Out‑Patient (VVIP, VIP, A Classes): 0-10 minutes
• Out‑Patient (B, C, D Classes): 0-15 minutes
• In‑Patient (All Classes): Less than 60 minutes
• Review and respond to approval requests as per policy coverage, requesting additional medical information when required to support appropriate decision‑making.
• Coordinate with medical providers to ensure appropriate care delivery and suggest cost‑effective treatment alternatives when medically appropriate.
• Maintain effective communication with healthcare providers not covered by field doctors to ensure continuity and quality of care.
• Obtain and review medical records and supporting documentation from providers during initial contact, with appropriate follow‑up through written correspondence.
• Liaise with medical providers and injured parties in cases involving medical treatment to coordinate appropriate and timely medical care.
• Improve the quality, clarity, and medical justification of approval responses while maintaining cost effectiveness of medical services.
• Identify and refer suspicious or high‑risk cases to the Fraud, Waste, and Abuse (FWA) team in line with internal guidelines.
• Ensure accurate documentation of all case activities, including contacts, decisions, and outcomes, within the system; submit billing or activity reports when applicable and required by standards.
• Participate in Learning & Development activities and complete a minimum of 25 training hours to maintain clinical, operational, and insurance knowledge.

QUALIFICATIONS & EXPERIENCE:

• Minimum Qualifications: Medicine Bachelor’s degree (MBBS).
• Licensed by the Saudi Commission for Health Specialties (SCFHS).

Minimum Related Experience: 1-3 years’ experience in related field.