3 Medical Appeals jobs in Saudi Arabia
Medical Claims Operation (Khobar)
Posted today
Job Viewed
Job Description
To ensure that assigned provider’s Outpatient claims will be medically & commercially adjudicated within the specified timeframe and within the targeted quality standards to achieve the business objective of delivering high quality claims statements.
Key Accountabilities:
1.Adjudication:
- Process all the daily batches of claims assigned in line with medical policy and adjudication guidelines while using medical his/her medical background in conjunction with the instructed guidelines, day-in-day-out for smooth operation of business activity.
- Assure that each Outpatient claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross checking with the electronic claims data on CAESAR, and reflecting the right decision for every claim on the operations system.
- Achieve daily target in terms number of claims without delaying claims unnecessarily.
2.Quality:
- To achieve required quality through achieving at least 95% accuracy level on monthly quality audits, in order to maintain the quality standard set for the job.
- Makes sound medical decisions that minimize the opportunity to be challenged by providers, and consults with seniors where in doubt.
3.Fraud and abuse identification:
- Reports abnormal trends of provider practice for adjudicated claims where needed.
- Detects and escalates fraud to the medical Unit Sections Head inline with the fraud guild lines.
***:
**Skills**:
- Bachelor's Degree in Pharmacy from an accredited Institution
- Clinical Experience
- Medical Insurance Experience preferable
**Education**:
Pharmacy
Manager - Medical Claims Operations (Pipeline)
Posted 8 days ago
Job Viewed
Job Description
To ensure that assigned provider’s Inpatient and Outpatient claims are medically & commercially adjudicated within the specified timeframe and within the targeted quality to achieve the business objective of delivering high-quality claim statements.
Adjudication- Process all daily batches of claims assigned in accordance with medical policy and Inpatient / Outpatient adjudication guidelines, utilizing medical expertise and instructed guidelines for smooth business operations.
- Ensure each claim is processed according to the checklist, including verification of physical claims or scanned images, cross-checking with electronic claims data on Edge, and reflecting the correct decision on the operations system.
- Achieve daily targets for the number of claims processed.
- Discuss high-profile or high-value claims with the claims medical manager when decisions are complex or require careful consideration.
- Maintain a minimum of 95% accuracy in monthly quality audits to meet quality standards.
- Make sound medical decisions that reduce the risk of challenges from providers, consulting with the medical manager when in doubt.
- Report abnormal provider practice trends related to adjudicated claims when necessary.
- Detect and escalate FWA (Fraud, Waste, and Abuse) cases to the relevant teams following claims handling guidelines.
Manager - Medical Claims Operations (Pipeline)
Posted 8 days ago
Job Viewed
Job Description
To ensure that assigned provider's Inpatient and Outpatient claims are medically & commercially adjudicated within the specified timeframe and within the targeted quality to achieve the business objective of delivering high-quality claim statements.
Adjudication- Process all daily batches of claims assigned in accordance with medical policy and Inpatient / Outpatient adjudication guidelines, utilizing medical expertise and instructed guidelines for smooth business operations.
- Ensure each claim is processed according to the checklist, including verification of physical claims or scanned images, cross-checking with electronic claims data on Edge, and reflecting the correct decision on the operations system.
- Achieve daily targets for the number of claims processed.
- Discuss high-profile or high-value claims with the claims medical manager when decisions are complex or require careful consideration.
- Maintain a minimum of 95% accuracy in monthly quality audits to meet quality standards.
- Make sound medical decisions that reduce the risk of challenges from providers, consulting with the medical manager when in doubt.
- Report abnormal provider practice trends related to adjudicated claims when necessary.
- Detect and escalate FWA (Fraud, Waste, and Abuse) cases to the relevant teams following claims handling guidelines.
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