Medical Claims Officer

Key Responsibilities

1. Claims Processing & Adjudication

• Review and process outpatient, inpatient, and reimbursement claims.

• Validate claims against policy coverage, exclusions, and limits.

• Ensure completeness of documentation (medical reports, invoices, prescriptions, discharge summaries).

• Validate medical coding (ICD, SBS) and ensure alignment with diagnosis and treatment.

• Assess medical necessity and appropriateness of services.

• Flag suspected overutilization, billing errors, duplications, upcoding, unbundling or inflated charges. and abuse, or fraud cases.

2. Policy Compliance

• Adhere to internal policies, SOPs, and regulatory requirements (e.g., CCHI in KSA).

• Apply contract terms (network agreements, tariffs, co-payments, deductibles).

3. Cost Control & Optimization

• Support cost-containment initiatives.

• Perform detailed review for high-value claims and agree on deals when applicable.

4. Communication & Coordination

• Liaise with healthcare providers for missing or unclear information through MCU team.

• Coordinate with medical approvals team when needed.

• Respond to internal queries (customer service, medical network, complaints, finance).

5. Turnaround Time (TAT) Management

• Process claims within defined SLA timelines.

• Prioritize urgent or high-value claims.

• Maintain productivity and quality benchmarks.

6. Fraud, Waste & Abuse (FWA)

• Identify suspicious claims and escalate as per protocol.

• Support investigations by providing medical insights.

Education:

• Bachelor of Science in Medicine, Dental Surgery or equivalent.

Experience:

• 1-3 years of experience in medical insurance.

• KSA regulatory and market knowledge

• Claims processing and auditing

Personal Attributes/ Skills:

Analytical and Decision-Making Skills:

• Ability to assess medical requests critically and make sound medical and technical decisions based on guidelines.

• Strong attention to detail for accurate documentation and reporting.

Technical Skills:

• Proficiency in using claims management software and other healthcare IT systems.

• Advanced skills in MS Office (Word, Excel, and PowerPoint) for reporting and documentation.

Time Management:

• Proven ability to handle high volumes of requests efficiently without compromising quality or compliance.

• Meet deadlines for all assigned tasks.

Teamwork:

• Collaborate effectively with internal and external stakeholders.

Problem-Solving:

• Quickly resolves Claims issues with professionalism and accuracy.

Preferred Attributes:

• Strong understanding of medical adjudication processes, medical terminology, and insurance claims.

• Ability to make accurate, timely decisions based on medical guidelines and claims software.

• Attention to detail and strong organizational skills to ensure all claims are processed efficiently.

Others:

• Fluency in English/Arabic