Description

Job Description

• JOB SUMMARY

The insurance doctor is responsible for managing all insurance-related activities for the hospital, ensuring that medical claims are accurate, compliant, and processed efficiently to maximize reimbursement and minimize denials. It is a hybrid role combining deep clinical knowledge, insurance expertise, data analysis, team leadership, and process improvement.

• KEY ACTIVITIES AND RESPONSIBILITIES

• Evaluate and process claims in accordance with insurance policy, terms and conditions, and MNGHA policies and procedures. Review medical reports and ensure proper entry and compatibility with the services provided by the hospital.
• Check the accuracy of medical information with supporting documents (i.e., laboratory, pharmaceutical, radiology, etc.).
• Communicate with the treating physician/medical team for any clarification or completion of missing information.
• Escalate pending cases to the concerned department and follow up directly with Medical Services. Coordinate and follow up with the approving officer(s) on discrepancies in the official form.
• Collaborate with the claims section team on clinical queries/requests to reassess the claims.
• Collaborate and communicate with insurance company representatives, such as claims adjusters or medical reviewers, to provide additional information or clarification about the medical services provided.
• Develop a billing system to improve Revenue Cycle Management (RCM) and decrease the number of rejections. Report any observations related to claims that may affect the RCM.
• Facilitate the reconciliation process, respond to rejected claims with proper justifications in accordance with the insurance requirements, and coordinate with the insurance companies for resubmission in a timely manner.
• Participate in establishing, developing, and implementing guidelines to evaluate and process medical claims.
• Assuring requires preauthorization or prior approval for specific treatments, procedures, or medications.
• Collect sufficient information for each issue and escalate it to the concerned department.
• Provide professional advice to subordinates on all aspects of medical insurance practice and law.
• Assume the responsibilities of Claims Analyst as and if required.
• Prepare and present necessary reports and correspondences as required by the Executive Management and Senior Executive Management.
• Perform other job-related duties.

• Key Result Areas

• Weekly/Monthly Claims Processed
• Coding & Documentation Accuracy
• Query Resolution Time
• Reduction in Missing Information
• Reduction in Claim Rejection/Denial Rate
• Reduction in Pending Cases
• Discrepancy Resolution
• Timely Resubmission
• Reduction in Write-offs
• Timeliness and accuracy of financial reports produced
• Number Reporting breaches identified
• Consolidations, Reporting & Analysis

• Qualifications

Degree in Medicine or equivalent

• Technical Skills
• Knowledge of CBAHI, Ministry of Health care policy and procedure.
• Knowledge of the health care sector.
• Knowledge of Medical coding, billing process and Clinical Documentation for RCM
• Clinical Understanding
• Work-stream leads, subordinates, healthcare team, physicians, insurance companies
• High paced environment with intense deadlines
• Great deal of details and accuracy

• Behavioural Skills
• Attention to Detail
• Professional Communication
• Analytical Skills: Ability to analyse denial trends and identify root causes
• Problem-Solving: Proactive in creating solutions to prevent future claim rejections
• Persistence & Follow-up: Tenacity in managing the appeals and resubmission process.
• Business Acumen
• Strategic Thinking
• Leadership Skills
• Ethical and Personal Integrity