Sunidhi M Shastry

Review and process outpatient prior authorization requests submitted by healthcare providers via GlobeMed systems (e.g., portals or integrated platforms).

• Verify member eligibility, benefit coverage, exclusions, and limits based on approved insurance policies.
• Assess medical necessity and clinical appropriateness in accordance with approved medical guidelines and internal policies.
• Ensure approvals or denials complied with UAE regulatory frameworks (DHA, DOH, MOHAP).
• Communicate authorization decisions clearly and professionally to providers within defined TATs (Turnaround Times).
• Defined key responsibilities for reviewing and processing outpatient prior authorization requests to ensure compliance and efficiency.
• Coordinate with medical reviewers / advisors for complex or high-cost cases requiring escalation.
• Handle resubmissions, clarifications, and additional documentation requests efficiently.
• Maintain accurate electronic records for audits, compliance checks, and reporting.
• Identified overutilization, unbundling, and non-covered services to support cost-containment initiatives within the organisation.
• Adhere strictly to internal controls, confidentiality, and data protection standards.

Strong understanding of outpatient medical services, CPT/ICD coding, and treatment pathways.

Knowledge of insurance policy structures, sub‑limits, exclusions, and clinical guidelines.

• Effective communication with providers and internal teams.
• Attention to detail and sound clinical judgement.
• Ability to work under pressure while maintaining SLA compliance.
• Proficiency in healthcare IT systems and TPA platforms.
• Highlighted essential skills and competencies for effective healthcare management.
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• Prescribed and administered medications while monitoring responses and adjusting treatment plans to optimise patient outcomes.
• Facilitated accurate diagnoses by integrating findings from examinations and test results, enhancing patient care.
• Performed thorough physical examinations and patient interviews to identify illnesses or injuries, contributing to effective treatment.