Medical Claims Officer

𝐉𝐎𝐁 𝐒𝐔𝐌𝐌𝐀𝐑𝐘
As a Medical Claims Officer, you will review and assess claims, handle pre-authorizations, adjudicate high-cost cases, and ensure compliance with coding, policy, and regulatory requirements while supporting cost containment and timely query resolution.

𝐐𝐔𝐀𝐋𝐈𝐅𝐈𝐂𝐀𝐓𝐈𝐎𝐍𝐒, 𝐒𝐊𝐈𝐋𝐋𝐒 & 𝐄𝐗𝐏𝐄𝐑𝐈𝐄𝐍𝐂𝐄:
1. Bachelor’s Degree in Medicine.
2. UAE-required insurance certifications/licenses.
3. ICD-10 & CPT coding knowledge.
4. 5+ years’ UAE medical insurance experience (Insurer/TPA preferred).
5. Proficient in MS Office (Advanced Excel) & analytical tools.

𝐉𝐎𝐁 𝐑𝐄𝐒𝐏𝐎𝐍𝐒𝐈𝐁𝐈𝐋𝐈𝐓𝐈𝐄𝐒:
1. Review claims against multidisciplinary notes, charts, physician orders, lab/radiology reports, drug charts, consultation and progress notes.
2. Assess DRG Severity of Illness in alignment with CPT/ICD coding.
3. Conduct utilization reviews for DRG cases, including bill verification, consumables markups, non-covered services, and overutilization checks.
4. Handle pre-authorization requests with detailed claim assessment on a daily basis.
5. Adjudicate high-cost claims at pre-authorization and submission levels in line with policy terms.
6. Ensure compliance with case management and cost-containment protocols for elective high-cost and medical management cases.
7. Provide second-opinion reviews to confirm appropriate treatment and recommend cost-effective alternatives, including network facilities or home-country treatment.
8. Respond to all claims queries within agreed turnaround times.
9. Stay updated on prevailing regulations and process/system changes.
10. Perform provider account reviews and reconciliations.