Medical Claims Manager
4 weeks ago
Medical Claims Manager (Approvals)
Summary :
Medical Claims Manager is responsible for supervising the daily work of the Medical Claims Department in providing quality service to clients, promptly and effectively according to operations set standards, TAT, and SLA. The position requires the ability to independently plan, schedule, organize, and respond appropriately to a variety of subjects and situations. Effective leadership and decision-making skills are crucial to achieve the goals of this position.
Main Tasks :
- Serve as the acknowledged expert and information source for staff.
- Follow medical guidelines, practices, and regulatory (AI) instructions.
- Set goals and priorities for the medical team and provide feedback about areas for improvement.
- Respond to employee questions/concerns on an individual basis as needed.
- Conduct and schedule staff development opportunities.
- Organize the establishment of effective cost containment plans, case management, and cost-saving for jumbo cases and high-cost management (referral and special discount).
- Update the Network Department with providers having issues with codes and prices, referral matrix, and centers of excellence.
- Raise suspected fraud and abuse providers to the Network and Fraud, Waste, and Abuse (FWA) departments.
- Provide accurate analytic data, insights, and recommendations to multiple stakeholders.
- Monitor adherence to policies and established procedures.
- Meet qualitative requirements and continuously work to improve the quality of approvals.
- Monitor the daily dashboard to ensure adherence to SLA, TAT, and productivity.
- Assist clients with escalated queries and provide suitable query resolution for other departments.
- Ensure participative leadership and strong communication within the team.
- Coach and develop the team with quality assurance and trending.
- Regularly evaluate and conduct root cause analysis for department enhancement.
- Increase automation percentage and accuracy and review the rules.
Minimum Requirements :
- Bachelor of Medicine and Bachelor of Surgery (MBBS).
- 8+ years of experience in a mid-to-large sized organization in a similar role.
- SCFHS.
- Typing and communication skills in English & Arabic.
- Physically fit to carry out duties.
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