Specialist - Medical Claims Operations (Bachelor of medicine and bachelor of surgery)

الوصف الوظيفي
Role Purpose:

To ensure that assigned provider’s Outpatient claims will be medically & commercially adjudicated within the specified time frame and within the targeted quality standards to achieve the business objective of delivering high quality claims statements.

Key Accountabilities:

Adjudication:

Process all the daily batches of claims assigned in line with medical policy and adjudication guidelines while using medical his/her medical background in conjunction with the instructed guidelines, day-in-day-out for smooth operation of business activity
Assure that each Outpatient claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross checking with the electronic claims data on CAESAR, and . reflecting the right decision for every claim on the operations system
Achieve daily target in terms number of claims without delaying claims unnecessarily
Quality:

To achieve required quality through achieving at least 95% accuracy level on monthly quality audits, in order to maintain the quality standard set for the job
Makes sound medical decisions that minimize the opportunity to be challenged by providers, and consults with seniors where in doubt
Fraud and abuse identification:
Reports abnormal trends of provider practice for adjudicated claims where needed
Detects and escalates fraud to the medical Unit Sections Head inline with the fraud guild lines
المهارات
Education:

Bachelor of medicine / Bachelor of surgery

Experience

Clinical Experience

Medical Insurance Experience preferable

تفاصيل الوظيفة
منطقة الوظيفة جدة, المملكة العربية السعودية
قطاع الشركة التأمين
طبيعة عمل الشركة صاحب عمل (القطاع الخاص)
الدور الوظيفي الطب والرعاية الصحية والتمريض
نوع التوظيف دوام كامل
الراتب الشهري غير محدد
عدد الوظائف الشاغرة غير محدد
المرشح المفضل
المستوى المهني متوسط الخبرة
عدد سنوات الخبرة الحد الأدنى: 2 الحد الأقصى: 5
الشهادة بكالوريوس/ دبلوم عالي

https://www.bayt.com/ar/saudi-arabia/jobs/specialist-medical-claims-operations-bachelor-of-medicine-and-bachelor-of-surgery-4187410/