Medical Claims Review Officer

Position Overview

We are seeking a highly skilled and detail-oriented Medical Claims Review Officer to join our dynamic team. In this critical role, you will be responsible for evaluating and verifying medical claims to ensure they meet clinical accuracy standards, policy coverage requirements, and medical guidelines. Your expertise will be instrumental in facilitating accurate claim adjudication while maintaining compliance with international and Saudi medical regulations. This position offers an opportunity to contribute to the efficient management of healthcare claims, collaborate with diverse stakeholders, and uphold the highest standards of ethical and operational excellence.

Key Responsibilities

• Claims Evaluation and Verification: Conduct thorough reviews of patient records, medical reports, and supporting documentation to validate the clinical accuracy and appropriateness of claims submitted for adjudication.
• Policy and Guideline Compliance: Ensure all claims adhere to established policy coverage and medical guidelines, including those set by international standards and the Saudi Commission for Health Specialties (SCFHS).
• Provider Communication and Justification: Provide clear and detailed medical justifications for claims that do not meet approval criteria, ensuring transparency and compliance with healthcare regulations. Engage in direct negotiations with healthcare providers to resolve disputes and reach mutually acceptable resolutions.
• Cross-Functional Collaboration: Work closely with other departments, such as finance, operations, and customer service, to verify claim amounts, statuses, and related information, ensuring seamless and accurate claims processing.
• Performance and Development: Achieve and maintain key performance indicators (KPIs) related to claims processing accuracy, turnaround time, and compliance. Participate actively in learning and development initiatives, completing a minimum of 25 training hours annually to stay abreast of clinical advancements, operational best practices, and evolving insurance regulations.
• Project Participation: Contribute to company-wide projects aimed at improving claims management processes, enhancing operational efficiency, and driving continuous improvement within the organization.

Qualifications and Requirements

• Educational Background: Hold a Bachelor’s degree in Medicine (MBBS) from a recognized institution.
• Professional Licensure: Must be licensed by the Saudi Commission for Health Specialties (SCFHS) and maintain an active license.
• Professional Experience: Possess a minimum of 2-3 years of post-graduation experience in medical claims review, clinical assessment, or other healthcare-related roles, with a proven track record in claims adjudication or related functions.
• Industry Knowledge: Demonstrate familiarity with insurance claim processes, healthcare regulations, and compliance requirements in the Kingdom of Saudi Arabia.
• Core Competencies:
  • Medical Expertise: Possess a strong foundation in medical knowledge, including clinical terminology, diagnostic criteria, and treatment protocols.
  • Communication Skills: Exhibit exceptional written and verbal communication abilities to articulate complex medical information clearly and professionally to stakeholders, including healthcare providers and internal teams.
  • Attention to Detail: Maintain a meticulous approach to reviewing claims and documentation to identify discrepancies, errors, or inconsistencies that may impact claim approvals.
  • Customer Orientation: Prioritize customer service by addressing provider inquiries promptly and professionally, fostering positive relationships and ensuring a high level of satisfaction.
  • Compliance and Ethics: Uphold the highest standards of ethical conduct and regulatory compliance, ensuring all actions align with organizational policies and legal requirements.
  • Time Management: Demonstrate strong organizational skills and the ability to prioritize tasks effectively, managing high volumes of claims while meeting deadlines and performance targets.

Why Join Us?

As a Medical Claims Review Officer, you will play a pivotal role in ensuring the integrity and efficiency of our claims management processes. You will have the opportunity to work in a collaborative and supportive environment, contribute to meaningful projects, and advance your professional development through ongoing training and learning initiatives. If you are a detail-oriented professional with a passion for healthcare and claims management, we invite you to apply and become a valued member of our team.