Medical Claims Operation (Khobar)

Job Description

Role Purpose:
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

Bachelor's degree in Nursing