Description

Job Description

• Evaluate and verify medical claims to ensure clinical accuracy and compliance with Policy Coverage and Medical guidelines.
• Review patient records, medical reports, and supporting documentation to facilitate accurate claim adjudication.
• Provide healthcare providers with medical justifications for rejected claims in line with international and Saudi medical guidelines.
• Negotiate and resolve disputed claims directly with Medical Service Providers when required.
• Collaborate with other departments to verify claim amounts, status, and related information.
• Support efficient, accurate, and compliant claims management through timely decision-making and communication.
• Achieve Key Performance Indicators (KPIs)
• Participate in Learning & Development activities and complete a minimum of 25 training hours to maintain clinical, operational, and insurance knowledge.
• Participate in Company Projects.
• Medicine Bachelor’s degree (MBBS).
• Licensed by the Saudi Commission for Health Specialties (SCFHS).
• 2-3 years of relevant experience post-graduation in medical claims review, clinical assessment or healthcare-related roles.
• Familiarity with insurance claim processes and healthcare regulations.
• Excellent Medical knowledge
• Good Communication Skills
• Attention to details
• Customer Orientation
• Compliance and Ethical Awareness