Medical Approval Officer

About the role

The Medical Approval Officer is responsible for evaluating and processing pre‑authorization requests for medical services, ensuring compliance with company policies, insurance guidelines, and medical necessity criteria. The role supports efficient service delivery for policyholders while maintaining high‑quality patient care.

Key responsibilities

• Verify eligibility and coverage of insured members.
• Evaluate requests for diagnostics, treatments, procedures, and hospital admissions against policy terms and medical necessity.
• Approve or deny requests, applying appropriate coverage exclusions and communicating decisions promptly to providers and policyholders.
• Maintain turnaround‑time (TAT) compliance for all pre‑authorization cases.
• Monitor utilization rates, detect early signs of fraud, waste, abuse or anti‑selection, and report findings.
• Manage inpatient case management, coordinate care plans, arrange second medical opinions and roving doctor visits when required.
• Review discharge plans and post‑discharge needs for coverage considerations.
• Accurately document all decisions in the company system while preserving confidentiality of medical records.
• Handle queries from providers, insurers and insured members, providing medical guidance to the Claims Department.

Required profile

• Minimum 24 months (2 years) experience in medical pre‑authorization, claims or utilization review.
• Familiarity with CCHI Unified Policy, CHI Implementing Regulations and Saudi health insurance guidelines.
• Ability to assess medical necessity, interpret clinical information and apply policy criteria.
• Strong analytical mindset with attention to detail for utilization monitoring and fraud detection.
• Excellent written and verbal communication skills in English.
• Commitment to maintaining confidentiality and adhering to legal and company regulations.

Required skills

• CPT coding
• Medical Terminology
• Pre‑authorization workflows
• NPHIES National Platform for Health Information Exchange Systems