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Medical Claims Officer

2 months ago

Riyadh, Ar Riyāḑ, Saudi Arabia Tabukpharmaceuticals Full time

Job Summary:

Tabuk Pharmaceuticals is seeking a highly skilled Medical Claims Officer to join our team in Riyadh, KSA. As a Medical Claims Officer, you will be responsible for processing medical claims in accordance with our company's policies and guidelines.

Key Responsibilities:

  1. Claims Processing: Process daily batches of claims, including direct billing and RI claims, in line with medical policy and inpatient adjudication guidelines.
  2. Target Achievement: Achieve daily targets for the number of claims processed within the defined regulatory timeframe.
  3. Eligible Benefits: Ensure that claims are paid as per the eligible benefit and coverage.
  4. High-Profile Claims: Discuss high-profile/high-value claims with the claims medical manager/TL where the decision is difficult and well-thought.
  5. Fraud Detection: Monitor and record medical abuse and refer suspected fraud claims to the Audit and investigation team.
  6. Price Discrepancies: Monitor prices and calculation discrepancies while processing claims and report over-invoiced claims and unagreed service codes to the relevant Network team.
  7. Medical Expertise: Apply medical skills and expertise to apply rejections wherever applicable.
  8. Additional Tasks: Assist in additional tasks whenever assigned by the claims Manager/TL.

Requirements:

Kindly submit your CV to be considered for this exciting opportunity.