Job Status : Active

π‰πŽπ π’π”πŒπŒπ€π‘π˜

As a Medical Claims Officer, you will be crucial in ensuring the accurate and efficient processing of medical insurance claims. This position offers an excellent opportunity for an experienced professional to contribute to the success and reputation of the medical department.

ππ”π€π‹πˆπ…πˆπ‚π€π“πˆπŽππ’, π’πŠπˆπ‹π‹π’ & π„π—ππ„π‘πˆπ„ππ‚π„:

1. Bachelor’s Degree in Medicine

2. Necessary certifications and licenses according to UAE regulations for insurance-related work.

3. Proficiency in ICD 10 & CPT coding.

4. Minimum of five years of experience in medical insurance within the UAE market, ideally with a Medical Insurer or Third-Party Administrator (TPA).

5. Strong proficiency in Microsoft applications, particularly Advanced Excel and analytical software.

π‰πŽπ π‘π„π’ππŽππ’πˆππˆπ‹πˆπ“πˆπ„π’:

1. Review documents such as multidisciplinary notes, TPR charts, physician orders, lab and radiology reports, drug charts, consultation and nursing notes, and progress notes to assess claims.

2. Conduct DRG Severity of Illness reviews aligned with CPT and ICD codes provided by the healthcare provider.

3. Conduct utilization reviews for DRG cases, covering final bill scrutiny, consumables markups, non-covered items/services, and service overutilization.

4. Handle Pre-authorization requests daily, providing detailed insight into claim specifics.

5. Adjudicate high-cost claims at pre-authorization and settlement stages, adhering to policy terms and conditions.

6. Follow case management and cost containment protocols for elective high-cost and medical management cases.

7. Review cases for second opinions when necessary for optimal management and cost containment, considering network facilities or home country treatment options.

8. Ensure timely responses to all claims queries.

9. Stay updated on regulations and system/process changes.

10. Conduct provider account reviews and reconciliations.

11. Prepare periodic portfolio analysis reports for management review.

12. Assist the department manager with any requested activities.

13. Provide support to the team as needed to ensure task completion runs smoothly.

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