Sr. Specialist - Pre-Arrangement & Admission (Health Insurance)

About the Role

Sr. Specialist - Pre-Arrangement & Admission at Allianz Ayudhya. Responsible for the pre-authorization process with two parts: pre-arrangement (pre-approve for procedure/surgery) and admission (initial approval for admission). Service both providers and members. Shift work: 8 am – 5 pm every day. Onsite, full-time.

Responsibilities

• Review claims and medical reports (medical indication assessment).
• Verify eligibility of claims and apply medical knowledge to pre-arrangement cases.
• Consult medical consultant team for cases with medical-necessity issues.
• Apply medical necessity guidelines (Thai Medical Practice Guidelines), determine coverage and implement cost containment measures.
• Send criteria checklist to consultant doctor and perform benchmark price & LOS comparison.
• Issue confirmation letters to providers within SLA (3 days).
• Control cost-effectiveness of medical care and assess appropriateness and safety of new procedures, drugs or technology.
• Study and apply A&H policy & coverage to pre-arrangement and admission processes.
• Coordinate with internal teams (corporate key accounts, care coordinator, medical team) and external teams (utilization nurses from hospitals).
• Collaborate with Health Concierge, Health Solutions & Care Coordination teams for screening, checklist submission, benchmarking, package price checking and provider negotiation.
• Detect suspicious, fraudulent or abusive claims and refer to Clinical Governance Team.
• Process medical coding (ICD codes) based on procedures and claims.

Qualifications

• Bachelor’s degree in Nursing Science or related field.
• Minimum 3 years nursing experience.
• Experience in critical units such as ER, ICU, OR is an advantage.
• Knowledge of claims management.
• Experience in health insurance-related topics.

Nice to Have

• Able to work in a commercial environment and fast-moving business.
• Customer relation management experience and experience managing customer relationships.
• Excellent interpersonal and communication skills.
• Familiarity with AI tools (e.g., ChatGPT, CoPilot365) is an advantage.

Additional Information

• Shift: 8 am – 5 pm, every day.
• Location: Onsite. Employment: Full-time.