Insurance Officer

2 weeks ago

Dammam, Eastern Province, Saudi Arabia 5CareNetwork Clinic Full time 60,000 - 120,000 per year

Insurance officer

Claims Reviewing:


• Manage all aspects of the day-to-day operations of claims production.


• Daily follow-up of HHC service provision in the branch with in-site team.


• Manage the complex general liability of claims.


• Supervising the implementation of best practices based on related authorities.


• Determine and delegate claims settlement authority to claims representatives.


• Identify strategic opportunities based on financial analysis and projections, cost/benefit identification and analysis.


• Discuss the complicated claims with team to help in preventing fraud.


• Ensure claim Performance quality.

Technical support:


• Provide support, guidance, leadership and motivation to promote maximum performance.


• Provide technical guidance to staff on claim investigation, reserving evaluation and resolution of claims.


• Keep the team up-to-date in regulations released by related authorities.


• Apply appropriate interventions and follow up on identified projects.

Rejection


• Analysis of rejection statement (medical / technical), and put plans to avoid them.


• Explain rejection reason to claim's team.

Project supervision


• Partner with related teams to produce necessary results.


• Interact extensively with various parties involved in the claim process.


• Conduct annual plan and budget preparation under guidance provided by leadership.


• Collaborate with other branches and business leaders to define and drive enterprise initiatives.


• Create an environment that encourages and values the opinions of others and promotes sharing of information and ideas.


• oriented in NPHEIS platform

Stakeholders' engagement


• Claim's activity reports for senior management (weekly - monthly).


• Preparing progression report.


• Provide staff with standards of performance and inform them of job expectations.


• Maintain good relationships and communication with payers.


• Regular meeting with partners leaders and submission of reports.

مسؤول التأمين

مراجعة المطالبات


• إدارة جميع جوانب العمليات اليومية لإعداد المطالبات.


• المتابعة اليومية لتقديم خدمات الرعاية الصحية المنزلية في الفرع مع فريق العمل الميداني.


• إدارة المسؤولية العامة المعقدة للمطالبات.


• الإشراف على تطبيق أفضل الممارسات بناءً على الجهات المختصة

.
• تحديد وتفويض صلاحية تسوية المطالبات لممثلي المطالبات

.
• تحديد الفرص الاستراتيجية بناءً على التحليل والتوقعات المالية، وتحديد وتحليل التكلفة والفائد

ة.
• مناقشة المطالبات المعقدة مع الفريق للمساعدة في منع الاحتيا

ل.
• ضمان جودة أداء المطالبا

ت.
• الدعم الف

ني
• تقديم الدعم والتوجيه والقيادة والتحفيز لتحقيق أقصى قدر من الأدا

ء.
• تقديم التوجيه الفني للموظفين بشأن التحقيق في المطالبات، وتقييمها، وتسويته

ا.
• إبقاء الفريق على اطلاع دائم باللوائح الصادرة عن الجهات المختص

ة.
• تطبيق التدخلات المناسبة ومتابعة المشاريع المحدد

ة.
• الر

فض
• تحليل بيان الرفض (الطبي/الفني)، ووضع خطط لتجنب

ه.
• شرح سبب الرفض لفريق المطالبة. الإشراف على المشر

وع
• التعاون مع الفرق ذات الصلة لتحقيق النتائج المطلوب

ة.
• التفاعل بشكل مكثف مع مختلف الأطراف المعنية بعملية المطالب

ة.
• إعداد الخطة السنوية والميزانية بتوجيه من القياد

ة.
• التعاون مع الفروع الأخرى وقادة الأعمال لتحديد مبادرات المؤسسة ودفعه

ا.
• تهيئة بيئة تشجع وتُقدّر آراء الآخرين، وتشجع على تبادل المعلومات والأف

كار.٠ موجه نحو منصة NP

H

EIS

إشراك أصحاب الم

صلحة
• تقارير نشاط المطالبة للإدارة العليا (أسبوعيًا - شه

ريًا).
• إعداد تقرير ا

لتقدم.
• تزويد الموظفين بمعايير الأداء وإطلاعهم على توقعات

العمل.
• الحفاظ على علاقات وتواصل جيدين مع الجهات ال

دافعة.
• عقد اجتماعات منتظمة مع قادة الشركاء وتقديم الت

قارير.

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