Description

Job Description

MedNet Egypt is one of the leading managed care service organizations that cater to healthcare needs. We are looking for skilled Senior Medical Reviewer – Rule Engine who will be responsible for managing, configuring, reviewing, testing, and continuously update automation and rule engines supporting Approvals and Claims automation, FWA detection, medical rules, and business requirement rules.

Your Job:

• Review, maintain, and optimize FWA, medical, and business requirement rules within the Medical Rule Engine.
• Manage rule logic related to fraud, abuse, waste detection, clinical appropriateness, benefit coverage, coding, and policy compliance.
• Conduct end-to-end testing, UAT, and validation of rules, including logic, thresholds, and performance checks.
• Ensure comprehensive documentation for rule logic, assumptions, testing, approvals, and audit trails.
• Monitor rule performance using KPIs such as accuracy, hit rate, savings/recovery, and claims correction impact.
• Identify and implement automation opportunities to improve productivity and reduce manual intervention.
• Collaborate with FWA, QA, Claims, Approvals, IT, Network, Production, and operational teams on system updates and enhancements.
• Support calibration of QA and FWA findings and align automation outputs with audit objectives.
• Coach colleagues on system logic, rule functionality, and automation best practices.
• Plan, map, review, and quality-check rule data, ensuring data accuracy before system deployment (beta and live).
• Define and execute testing scenarios and ensure implementation aligns with approved plans and technical developments.
• Ensure rule maintenance and development comply with governance frameworks and stakeholder communication requirements.
• Coordinate stakeholder meetings, manage progress and maintenance reporting, and support timely delivery of medical review automation initiatives.

Your Profile:

• Bachelor’s degree in medicine, pharmacy & dentistry or related fields.
• 2-3 years of experience in the Health Insurance industry with Insurer/TPA specifically with experience in automation, rule engine, audit, claims and approvals automation.
• Industry knowledge related to the local health services system is a plus
• Strong understanding of claim auditing, QA frameworks, and workflows, automation and rules configuration.
• Strong understanding of rule engines, automation logic, and claims systems.
• Knowledge of medical coding (ICD, CPT) and clinical/claims workflows
• Strong analytical thinking and attention to details
• Strong documentation and communication skills
• Good command of English and computer literacy