Medical Claims Officer

Key Responsibilities 1. Claims Processing & Adjudication - Review 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 Compliance - Adhere to internal policies, SOPs, and regulatory requirements (e.g., CCHI in KSA). - Apply contract terms (network agreements, tariffs, co-payments, deductibles). 3. Cost Control & Optimization - Support cost-containment initiatives. - Perform detailed review for high-value claims and agree on deals when applicable. 4. Communication & Coordination - Liaise 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) Management - Process 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 knowledge - Claims processing and auditing Personal 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