3 Medical Appeals jobs in Saudi Arabia

Job title:
Supervisor - Medical Claims Processing

Duties and Responsibilities:

Claims Processing Oversight

• Support the Manager in supervising daily claims / batch intake, validation, adjudication, and settlement activities.
• Ensure compliance with
  Nphies e-claims standards
  , coding standards, MDS and timeline specified per regulations.
• Monitor turnaround times (TAT) to meet internal and external service-level agreements (SLAs).

Quality Assurance & Compliance

• Assist in implementing internal controls to ensure claims accuracy and prevent fraud, waste, and abuse.
• Coordinate with internal audit and compliance teams to maintain adherence to CCHI guidelines and regulatory directives.
• Contribute to training programs for staff and providers on correct claims submission and reconciliation processes.

Discrepancy Resolution

• Oversee investigation of claim discrepancies, rejections, and denials, and ensure timely resolution.
• Support communication with healthcare providers, external and internal teams / stakeholders to address recurring issues.
• Escalate unresolved or high-impact discrepancies to the Senior Claims Manager with recommended solutions.

Stakeholder Management

• Act as deputy contact point for healthcare providers, external and internal stakeholders and claims staff.
• Provide guidance to healthcare providers on claims processing requirements and Nphies compliance.
• Participate in regular meetings with hospitals, clinics, and pharmacies to strengthen provider relations.

Reporting & Continuous Improvement

• Prepare operational dashboards and performance reports for management review.
• Support process re-engineering projects to reduce rejections and enhance claims accuracy.

People Management & Performance

This role is critical for the day-to-day leadership and performance development of the claims processing team, which is vital for a Tier 1 insurance company's operational excellence.

1. Team Oversight & Support:
   Supports the Manager in supervising daily claims intake, validation, adjudication, and settlement activities.
2. Training & Development:
   Contribute to training programs for staff and providers on correct claims submission and reconciliation processes.
3. Performance Management (Tactical):
   Oversee investigation of claim discrepancies, rejections, and denials, and ensure timely resolution. Identify trends in denials and contribute to corrective action plans.
4. Risk & Compliance Culture:
   Acts with due diligence to safeguard company interests. Maintain highest level of confidentiality.

KPI Monitoring, Reporting, and Continuous Improvement

This area transforms raw claims data into actionable insights for management, a non-negotiable for a large insurer focused on efficiency and cost control.

1. KPI Monitoring:
   Monitor turnaround times (TAT) to meet service-level agreements (SLAs). Support the oversight. of the end-to-end claims processing management cycle. TAT/SLA Compliance: Time taken from claim receipt to final settlement. First-Pass Ratio (FPR): Percentage of claims processed without manual intervention or rejection.
2. Reporting & Analysis:
   operational dashboards and performance reports for management review. Identify trends in denials.
3. Continuous Improvement:
   process re-engineering projects to reduce rejections and enhance claims accuracy.

Education:

Bachelor's degree in Medicine / Pharmacy, Healthcare Administration, Business Administration or Health Informatics.

Experience:

• Hands-on experience in Medical Claims Processing domain (3–5 years minimum)
• Healthcare Insurance & Regulatory Compliance (5+ years preferred)
• Understanding of Medical Claims Processing

Personal Attributes / Skills:

1. Integrity & Ethical Mindset
   – Strong moral principles to handle sensitive financial and healthcare data responsibly.
2. Attention to Detail
   – Ability to spot anomalies, inconsistencies, and patterns in data.
3. Analytical Thinking
   – Logical approach to problem-solving and decision-making.
4. Critical Thinking
   – Evaluating evidence to determine fraud risks and compliance gaps.
5. Persistence & Patience
   – Fraud investigations and reconciliations can be complex and time-consuming.
6. Communication Skills
   – Clear reporting of findings to internal teams, auditors, and regulators.
7. Confidentiality & Discretion
   – Handling sensitive patient and financial information with care.
8. Adaptability
   – Keeping up with evolving fraud schemes and regulatory changes.

Others:

• Fluency in Arabic language, working knowledge of the English language is an advantage.
• Proficiency in using Microsoft Office applications and database management.
• Ability to work independently and as part of a team to achieve network management goals.

MEDICAL CLAIMS ANALYST

Corporate

Unit Manager

Independent contributor role focused on specialized claims adjudication and pattern recognition. Responsible for handling trend-based claims while identifying process improvements and serving as a resource for junior staff.

5%

• Identify emerging claim patterns and propose minor process improvements

• Contribute to workflow optimization through trend analysis

95%

• Independently review specialized and trend-based medical/dental claims
• Apply clinical and policy knowledge to complex scenarios
• Identify patterns in claim data and propose process improvements
• Conduct self-audits on 10% of own work for accuracy against clinical guidelines
• Draft initial responses to provider disputes for supervisor review
• Serve as resource for Level 1 staff on common claim scenarios
• Maintain expertise in current policy and clinical guidelines

Bachelor degree in healthcare administration, business, or related field preferred

2-4 years of claims processing experience in healthcare or insurance

Arabic : Advanced

English : Advanced

• Accounts Receivable
• Billing Investigations
• Billing Statement Preparation

• Excellence
• Integrity
• Accountability
• Cybersecurity
• Person-Centered Care

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.