1. Position details Position: CMO PAN India Preauth Head Department: Operations Location: Bangalore Grade: CMO Reporting to: CEO Position 2. Responsibilities: Preauthorization Operations Lead and manage the Preauthorization process across India, ensuring consistent and efficient approval of medical procedures, treatments, and hospital admissions in alignment with company policies, medical guidelines, and insurance regulations. Oversee the preauthorization team, providing leadership, guidance, and support to medical officers, claims teams, and other stakeholders involved in the preauthorization process. Develop and implement standard operating procedures (SOPs) and medical guidelines for preauthorization, ensuring alignment with industry standards and regulatory requirements. Ensure timely and accurate reviews of medical cases, with a focus on clinical appropriateness, fraud prevention, and cost-effectiveness. Fraud and Abuse Management Lead the development and implementation of strategies to detect, prevent, and manage fraud and abuse within the preauthorization process. Collaborate closely with the claims, legal, and risk management teams to identify and mitigate fraud risks across medical claims and preauthorization. Establish robust fraud detection mechanisms, such as medical audits, claim verifications, and data analytics, to monitor and flag potentially fraudulent activities in preauthorization requests. Provide training and guidance to the preauthorization team on recognizing signs of fraud, abuse, and misuse of insurance policies. Conduct in-depth investigations into potential fraudulent preauthorization requests, ensuring medical and ethical standards are maintained. Regulatory Compliance & Risk Mitigation Ensure that preauthorization processes are compliant with relevant healthcare regulations, insurance guidelines, and medical ethical standards. Monitor and keep up to date with regulatory changes, and adapt the companys preauthorization and fraud prevention strategies as needed to ensure continued compliance. Regularly review and audit preauthorization cases to ensure adherence to regulatory requirements and company policies. Work closely with the legal and compliance teams to address any potential legal risks related to medical reviews, fraud management, or abuse in preauthorization processes. Medical Training & Development Develop and conduct training programs for the medical, claims, and preauthorization teams on clinical guidelines, fraud prevention techniques, and company policies. Educate and engage external healthcare providers, partners, and network hospitals on the importance of proper preauthorization practices and fraud detection. Foster a culture of continuous medical education and ethical decision-making within the organization. Data-Driven Insights & Reporting Utilize data analytics to track preauthorization trends, identify potential fraud patterns, and improve the overall efficiency of the preauthorization process. Regularly report on preauthorization outcomes, fraud management activities, and overall medical claims performance to the CEO and senior leadership team. Provide actionable insights to improve clinical processes, reduce fraud, and enhance customer satisfaction with the preauthorization process. Collaboration with Internal & External Stakeholders Work closely with other departments, including claims, customer service, risk management, and compliance, to ensure a seamless preauthorization workflow. Represent the company in discussions with external stakeholders such as insurance partners, healthcare providers, and regulatory bodies, advocating for high standards in preauthorization, fraud prevention, and medical ethics. Foster strong relationships with healthcare professionals and partners to streamline preauthorization processes and resolve challenges in a timely manner. 3. Qualifications and Experience required for the position MBBS degree with MCI is mandatory. At least 8-10 years of experience in a senior medical role within healthcare, insurance, or TPA sectors. Proven experience leading preauth operations at a PAN India level, or in a large-scale healthcare/insurance organization.
