Medical Claims Manager
3 weeks ago
Medical Claims Manager (Approvals)
- Serve as the acknowledged expert and information source for staff
- medical guidelines, practices and regulator ( AI ) instructions.
- Setting goals and Priorities for medical team and Provide feedback about areas for improvement
- Respond to employee questions / concerns on individual basis as needed
- Conduct and schedule staff development opportunities
- Organized Establishment of effective cost containment plans, Case management and Cost Saving for jumbo cases and high cost management ( referral and special discount )
- Update Network Department with providers having issues with Codes and Price, Referral Matrix and Centers of Excellence
- Raise suspected fraud and abuse provider to 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 the qualitative requirements and continuously work to improve quality of approvals.
- Monitoring of the daily dashboard to ensure adherence to SLA, TAT and the productivity
- Assist clients with escalated queries and provide suitable query resolution for other departments
- Ensuring participative leadership and strong communication within the team
- Coaching and team Development with quality assurance and trending
- Regular evaluation and 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 the similar role.
- SCFHS
- Typing and communication skills in English & Arabic.
- Physically fit to carry out duties.
Job ID 67744
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