Job Description

RESPONSIBILITIES AND DUTIES

Research and follow up on Medical Treatment patterns and conduct utilization reviews for Beneficiaries (Policyholders) & Medical Network providers, Quality control by:

Being available (On call) 24 hours a day for Claim Centre Officers queries relating to in-patient claims.

Assess day-care and in-patient cases as per medical justification and policy coverage.

Issuing day-care and in-patient cases within AED 15,000.00 for medically justified cases in line with the policy.

Escalate and confirm grey-area cases. Confirming of exclusions of borderline cases OP/IP.

Assists CC officers and supervisors in claims adjudication cases as needed.

Sending request of confirmation and notification to corresponding payers as needed.

Responding to payer's queries in relation to day-care and In-patient cases.

Responding to the payers request for advice on coverage of cases.

Monitor Claims cost as per internal guidelines.

Rejecting medically unjustified and policy wise excluded day-care and in-patient cases to be signed by Chief Medical Officer.

Conformity of assessment for the prescribed tests/medications/investigations/clinical procedures

Issuing day-care and In-patient cases Reimbursement Approval in line with medical and policy coverage.

Contacting provider for queries and clarifications.

Doing clinical discussion directly with the network's doctor as needed.

Seeking verbal clinical opinion from Network's doctor as needed.

Document and report to CC Supervisor, Assistant Manager and Manager any suspected fraud cases.

Monitoring and maintaining the claims processing and adjudicating cycle in operational software system as per the defined terms and policy of the organization.

Establishing strategies and implementing effective parameters for solving all possible queries within the team.

Taking a lead role in assuring that the assigned tasks to the team are completed within the allocated time frame.

Ensures the proper communication and implementation of new formats, training and processing rules.

Entering and processing/ adjudicating claims in operational software system as per the terms and policy of the organization.

Taking initiatives to maximize team efficiency.

Maintaining both qualitative and quantitative claims measures.

Achieving required processing targets assigned by the team-leader on daily, weekly and monthly basis.

Monitor the qualitative and quantitative measures for IP-claims & pre-approvals.

Ensure compliance to any changes in terms of system parameters or process.

Assisting the CC Supervisors / Asst. Manager and Managers as needed.

Any additional duties commensurate with your position as may be assigned to you from time to time by the Company.

3. KNOWLEDGE, SKILLS AND EXPERIENCE

Medical Doctor (MBBS degree/ MD degree)

2 - 3 years' experience in the healthcare industry/hospitals is mandatory

Basic Industry knowledge (healthcare/insurance) is a plus.

Should be a team-player with an aptitude for customer service

Must be service oriented

Highly decisive with outstanding logic and reasoning skills

Excellent oral and written communication skills

Must be computer literate

Excellent command of the English language, Arabic is a plus

Candidate must be tactful and discrete when dealing with clients and must be able to handle confidential information

Ability to work under pressure and meet tight deadlines and varying work-schedules

Job Types: Full-time, Permanent

Pay: AED9,000.00 - AED10,000.00 per month

Education:

• Bachelor's (Preferred)

Experience:

• Hospital: 2 years (Preferred)
• Medical Insurance: 1 year (Preferred)