Medical Claims Department Lead

2 weeks ago

Khobar, Eastern Province, Saudi Arabia Nextcare Full time

About Us:

At Nextcare, we strive to deliver exceptional patient care and service. Our commitment to quality and innovation has earned us a reputation as a leader in the healthcare industry.

Job Overview:

This role plays a critical part in ensuring the smooth operation of our Medical Claims Department. As Medical Claims Manager, you will be responsible for supervising a team of professionals who process claims efficiently and effectively.

  • You will need to have 8+ years of experience in a mid-to-large sized organization in a similar role.
  • A Bachelor of Medicine and Bachelor of Surgery (MBBS) degree is required.
  • You should possess excellent communication and typing skills in English & Arabic.

Main Tasks:

Your key responsibilities will include:

  • Overseeing the daily work of the Medical Claims Department.
  • Following medical guidelines, practices, and regulatory instructions.
  • Setting goals and priorities for the medical team.
  • Providing feedback on areas for improvement.
  • Conducting and scheduling staff development opportunities.
  • Organizing effective cost containment plans, case management, and cost-saving strategies.
  • Updating the Network Department with providers having issues with codes and prices.
  • Raising suspected fraud and abuse providers to the Network and FWA departments.
  • Providing accurate analytic data, insights, and recommendations to multiple stakeholders.
  • Monitoring adherence to policies and established procedures.
  • Meeting qualitative requirements and continuously improving the quality of approvals.
  • Monitoring the daily dashboard to ensure adherence to SLA, TAT, and productivity.
  • Assisting clients with escalated queries and providing suitable query resolution for other departments.
  • Ensuring participative leadership and strong communication within the team.
  • Coding and developing the team with quality assurance and trending.
  • Regularly evaluating and conducting root cause analysis for department enhancement.
  • Increasing automation percentage and accuracy and reviewing 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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