Approval Specialist

About the role

The Approval Specialist ensures that all medical services comply with the Council of Health Insurance (CHI) pre‑authorization policy, NPHIES standards, and individual payer coverage rules. This role prevents unauthorized or non‑contracted services from being initiated and supports timely approvals for discharges and high‑cost procedures.

Key responsibilities

• Verify clinical documentation completeness and use of the Minimum Data Set (MDS) for each request.
• Review physicians’ progress notes, diagnostics, prescriptions, and justifications for accuracy and medical necessity.
• Validate coding and scheme linkage to avoid claim denials.
• Escalate incomplete or inaccurate documentation before submission.
• Communicate approvals, denials, and payer queries within CHI‑mandated timelines and respond to payer queries within 30 minutes.
• Prioritize urgent cases (ER, ICU, Oncology, high‑cost procedures) and notify the Preauthorization Manager immediately.
• Monitor HIS/NPHIES queues, update approval status in systems, and ensure same‑day discharge approvals.
• Document all approvals, denials, and communications in the patient’s medical record.
• Participate in daily discharge reconciliation and report pending approvals.
• Review preauthorization rejections twice per shift, categorize reasons, and log details in the Rejection Tracker.
• Coordinate with physicians to obtain missing documentation and provide feedback to prevent future rejections.
• Resubmit corrected documentation within payer appeal windows and confirm acknowledgment.
• Identify root causes of rejections and document corrective recommendations.

Required profile

Required skills