Job Description

Summary:

The Clinical Insurance Officer is responsible for managing all insurance-related processes for home healthcare patients, including pre-authorizations, renewals, and claim documentation. The role ensures that all clinical and administrative requirements are met in compliance with payer guidelines, Department of Health (DOH) standards, and internal policies.

Roles & Responsibilities:

• Obtain, monitor, and renew insurance pre-authorizations for all homecare services (e.g., nursing, physiotherapy, medical, and multidisciplinary care).
• Verify patient insurance eligibility and coverage before initiating or renewing services.
• Coordinate with insurance companies and third-party administrators (TPAs) to secure approvals and address pending or rejected requests.
• Liaise with physicians and clinical staff to complete and submit all required medical reports and treatment plans.
• Ensure all insurance forms including DAMAN Forms (PAFs, progress notes, medical reports) are properly signed, stamped, and compliant with DOH and payer requirements.
• Track authorization validity to prevent service interruptions for active patients.
• Score medical condition and services for new and established patients.
• Follow up with insurance company regarding required reports or information.
• Determining the correct codes for patient records
• Prepare all reports and documents required by insurance company to grant pre-approval as (collection and arrange the reports, face to face, consent form, license of nurses, physiotherapy & Doctor, nursing care plan, physiotherapy plan and assessment, Scoring grid)
• Review clinical documentation to ensure it supports medical necessity for services billed to insurance.
• Verify that patient records, including Periodic Assessment Forms (PAFs) and treatment notes, align with the approved authorization scope and duration.
• Identify incomplete or inconsistent documentation and coordinate with clinicians for prompt correction
• Keeping track of patients hospital admission, ER visits and discharges.
• Prepare monthly report as Patient movement, daman allocation, admission and discharge
• Daily submission of staff capacity to daman.
• Prepare and submit JAWDA KPI report and act as JAWDA KPI data collector.
• Collect and save all KPI reports.
• Perform other duties as assigned by management..

Qualifications

• Bachelor of Nursing
• 2+ years’ experience in a similar role
• Advanced understanding of medical terminology and administration processes