Requirements
Bachelor of Science in Medicine, Dental Surgery or equivalent. 1-3 years of experience in medical insurance, KSA regulatory and market knowledge, and claims processing and auditing. Must possess analytical and decision-making skills, strong attention to detail, proficiency in claims management software and MS Office, excellent time management, teamwork, and problem-solving abilities. Fluency in English/Arabic is required.
Description
Key Responsibilities1. Claims Processing & AdjudicationReview and process outpatient, inpatient, and reimbursement claims.Validate claims against policy coverage, exclusions, and limits.Ensure completeness of documentation (medical reports, invoices, prescriptions, discharge summaries).Validate medical coding (ICD, SBS) and ensure alignment with diagnosis and treatment.Assess medical necessity and appropriateness of services.Flag suspected overutilization, billing errors, duplications, upcoding, unbundling or inflated charges. and abuse, or fraud cases.2. Policy ComplianceAdhere to internal policies, SOPs, and regulatory requirements (e.g., CCHI in KSA).Apply contract terms (network agreements, tariffs, co-payments, deductibles).3. Cost Control & OptimizationSupport cost-containment initiatives.Perform detailed review for high-value claims and agree on deals when applicable.4. Communication & CoordinationLiaise with healthcare providers for missing or unclear information through MCU team.Coordinate with medical approvals team when needed.Respond to internal queries (customer service, medical network, complaints, finance).5. Turnaround Time (TAT) ManagementProcess claims within defined SLA timelines.Prioritize urgent or high-value claims.Maintain productivity and quality benchmarks.6. Fraud, Waste & Abuse (FWA)Identify suspicious claims and escalate as per protocol.Support investigations by providing medical insights.Education: Bachelor of Science in Medicine, Dental Surgery or equivalent.Experience:1-3 years of experience in medical insurance.KSA regulatory and market knowledgeClaims processing and auditingPersonal Attributes/ Skills:Analytical and Decision-Making Skills:Ability to assess medical requests critically and make sound medical and technical decisions based on guidelines.Strong attention to detail for accurate documentation and reporting.Technical Skills:Proficiency in using claims management software and other healthcare IT systems.Advanced skills in MS Office (Word, Excel, and PowerPoint) for reporting and documentation.Time Management:Proven ability to handle high volumes of requests efficiently without compromising quality or compliance.Meet deadlines for all assigned tasks.Teamwork:Collaborate effectively with internal and external stakeholders.Problem-Solving: Quickly resolves Claims issues with professionalism and accuracy.Preferred Attributes:Strong understanding of medical adjudication processes, medical terminology, and insurance claims.Ability to make accurate, timely decisions based on medical guidelines and claims software.Attention to detail and strong organizational skills to ensure all claims are processed efficiently.Others:Fluency in English/Arabic