Approval & External Referral Lead

23 hours ago

Cairo, Egypt OneHealth Full time

OneHealth is a world-class healthcare provider present in Egypt, Nigeria & expanding in Africa; offering high-quality medical services alongside a unique customer journey. The goal is simple - to revolutionize the healthcare industry through a seamless customer experience, whether it is in physical branches via state of the art medical centers or virtually through 24/7 access to teleconsultation via digital channels.

With a global mindset that aims at elevating the customer healthcare journey, OneHealth medical centers offer one-stop-shop healthcare services by providing access to over 30 medical specialties and sub-specialties, advanced diagnostics, laboratory services, and electronic medical records for all customers, which makes going to the medical center or consulting a doctor virtually, a medical experience like no other

OneHealth is owned by AXA Group and is on a mission to provide exceptional healthcare solutions in emerging markets serving both insured and non-insured customers; and to make healthcare an affordable, trusted and above all convenient experience that all clients deserve.

Objective:

- To facilitate and track patient care that are referred to 3rd party providers for surgeries, procedures, etc.
- To improve clinical outcomes, checkup process, increase patient satisfaction, and promote cost-effectiveness.
- Manage and Control the possible leakage of referred cases.
- SPOC between OH doctors, 3rd party internal/external providers, and patients

**_ Planning_**:

- Provide education to team members, frontliners, physicians, patients, and providers regarding prior authorization process.
- Determine the requirement for prior authorization based on the service type, ICD-10 code, CPT/HCPC code or place of service

**_ Functional_**:

- Coordinate and facilitate patient care with 3rd party external providers, for both OOP and insured customers.
- Serves as the primary liaison/ main point of contact between physicians, 3rd parties, the patient, and collaboratively with various members of life checkup team, approval team, claims team, treatment providers, vendors. and community resources to coordinate transition till discharge
- Communicate patient needs to a variety of care team members and follow up accordingly to improve clinical outcomes & increase patient satisfaction.
- Work collaboratively with patients, physicians, 3rd parties, hospitals, to ensure high quality care and performs post - discharge follow up calls.
- Responsible for the daily medical validation of the Prior Authorization of referral to make sure that approval is covering the requested services with all stakeholders.
- Interact with providers to gather complete, accurate information in order to provide patient with smooth process as well to ensure all services were performed appropriately.
- To perform various administrative tasks, among which include maintaining patient case files in Electronic Medical Record.
- Review Hospital course report in comparing it with preapproval and checkup groups/ requests to avoid any claim rejection and meeting the insurance policy.
- Responsible for data entry into the Electronic Medical Record in a timely manner, review accuracy and completeness of information requested and ensure that all supporting documents are uploaded/present.
- Responsible to support required processes of the medical team members and providers as well as facilitates the timely processing of documentation submitted to the Medical Management department
- Acting as focal point to make sure that all physicians are fulfilling & maintaining accurate patient note in case of not approving a request, or awaiting additional information for referral requests.
- Guide Patients through the processes and regulations related to their cases
- Performs data entry & filing and Responsible for daily administrative functions to review requests for medical appropriateness and validate preauthorization.
- Arranges first post - discharge appointments for our patients.
- Proper implementation of agreements on invoices and claims in collaboration with the audit and processing team.
- Review ICD-10 codes for accuracy and existence of coverage specific to the line of business and company policies and regulations.
- Manage requests for tracking, managing, and reporting of those referral and checkup requests to Top management in weekly/ month basis, as well analyzing referral metrics to improve outcomes.
- Be proactive and follow up on open cases, step by step, day-to-day activities.
- Highlight and report fraud, abuse, and anti-selection to Management.

**_ People_**:

- Coordinate and maintain providers, patients & Physician's relations to ensure smooth operation of referral and consideration is given to unique treatment
- Communicate between payers, insurance companies and medical manager to solve complex cases and do the necessary reconciliations
- Regularly assisting patients by answering questions and resolving issues that may arise duri

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