Medical Claims Officer

Position Overview

We are seeking a highly organized and detail-oriented Medical Claims Officer to join our dynamic team. In this critical role, you will be responsible for reviewing, processing, and adjudicating medical claims with precision, ensuring compliance with regulatory standards and internal policies. Your expertise in medical insurance, claims validation, and cost control will play a pivotal role in maintaining operational efficiency while safeguarding against fraud, waste, and abuse. If you possess a strong background in medical insurance, a keen analytical mindset, and the ability to collaborate effectively with healthcare providers and internal stakeholders, we invite you to apply for this opportunity.

Key Responsibilities

The Medical Claims Officer will be tasked with a diverse range of responsibilities, including:

• Claims Processing & Adjudication:
  • Review and process outpatient, inpatient, and reimbursement claims with meticulous attention to detail.
  • Validate claims against policy coverage, exclusions, and predefined limits to ensure accuracy.
  • Ensure the completeness of documentation, including medical reports, invoices, prescriptions, and discharge summaries.
  • Validate medical coding (ICD, SBS) to confirm alignment with diagnosis and treatment protocols.
  • Assess the medical necessity and appropriateness of services rendered.
  • Identify and flag potential issues such as overutilization, billing errors, duplications, upcoding, unbundling, inflated charges, and suspected fraud or abuse cases.
• Policy Compliance:
  • Adhere strictly to internal policies, standard operating procedures (SOPs), and regulatory requirements, including those set by the Council for Cooperative Health Insurance (CCHI) in the Kingdom of Saudi Arabia.
  • Apply contract terms, such as network agreements, tariffs, co-payments, and deductibles, to ensure fair and accurate claim settlements.
• Cost Control & Optimization:
  • Support cost-containment initiatives by performing detailed reviews of high-value claims and negotiating favorable terms where applicable.
• Communication & Coordination:
  • Liaise with healthcare providers to obtain missing or unclear information through the Medical Claims Unit (MCU) team.
  • Coordinate with the medical approvals team to resolve complex or high-risk claims.
  • Respond promptly and professionally to internal queries from customer service, medical network, complaints, and finance departments.
• Turnaround Time (TAT) Management:
  • Process claims within defined Service Level Agreements (SLAs) to maintain operational efficiency.
  • Prioritize urgent or high-value claims to ensure timely resolution.
  • Uphold productivity and quality benchmarks to deliver consistent results.
• Fraud, Waste & Abuse (FWA) Detection:
  • Identify suspicious claims and escalate them in accordance with established protocols.
  • Provide medical insights to support investigations into potential fraudulent activities.

Qualifications & Experience

To excel in this role, candidates must meet the following criteria:

• Education: A Bachelor of Science degree in Medicine, Dental Surgery, or an equivalent qualification from a recognized institution.
• Experience:
  • 1-3 years of hands-on experience in medical insurance, with a strong understanding of claims processing and auditing.
  • Familiarity with the healthcare regulatory landscape and market dynamics in the Kingdom of Saudi Arabia.
• Technical Skills:
  • Proficiency in using claims management software and other healthcare IT systems to streamline workflows.
  • Advanced skills in Microsoft Office Suite (Word, Excel, and PowerPoint) for reporting, documentation, and data analysis.
• Personal Attributes:
  • Analytical & Decision-Making Skills: Ability to critically assess medical requests and make informed medical and technical decisions based on established guidelines.
  • Attention to Detail: Ensures accuracy in documentation, reporting, and claim validation.
  • Time Management: Proven ability to handle high volumes of requests efficiently while maintaining quality and compliance standards.
  • Teamwork & Collaboration: Works effectively with internal and external stakeholders to resolve issues and achieve organizational goals.
  • Problem-Solving: Addresses claims issues with professionalism, accuracy, and a solutions-oriented approach.
• Preferred Attributes:
  • In-depth understanding of medical adjudication processes, medical terminology, and insurance claims.
  • Ability to make accurate and timely decisions based on medical guidelines and claims software.
  • Strong organizational skills to ensure all claims are processed efficiently and in compliance with regulatory requirements.
• Language Proficiency: Fluency in both English and Arabic is required to facilitate seamless communication with diverse stakeholders.

Why Join Us?

As a Medical Claims Officer, you will play a vital role in ensuring the integrity of our claims processing system while contributing to cost-effective healthcare solutions. This position offers the opportunity to work in a collaborative environment, leverage your medical expertise, and make a tangible impact on the organization’s operational success. If you are a detail-oriented professional with a passion for healthcare and insurance, we encourage you to apply and become an integral part of our team.