Manager - Medical Claims Operations (Pipeline)

دوام كامل في Almajdouie في Saudi Arabia

نُشرت يوم February 4, 2025

تفاصيل الوظيفة

Manager - Medical Claims Operations (Pipeline) Job Description To ensure that assigned provider’s Inpatient and Outpatient claims are medically & commercially adjudicated within the specified timeframe and within the targeted quality to achieve the business objective of ensuring that BUPA delivers high quality claim statements. Adjudication

Process all the daily batches of claims assigned in line with medical policy and Inpatient / Out-patient adjudication guidelines while using his/her medical background in conjunction with the instructed guidelines.
Assure that each claim has been processed as per the checklist of steps involving checking of physical claims (or scanned image on the document management system), and cross-checking with the electronic claims data on Edge, reflecting the right decision for every claim on the operations system.
Achieve daily target in terms of number of claims processed.
Discuss all high profile/high value claims with the claims medical manager where the decision is difficult & well thought.

Quality

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.
Make sound medical decisions that minimize the opportunity to be challenged by providers, and consult with the medical manager where in doubt.

Fraud and Abuse Identification

Report abnormal trends of provider practice for adjudicated claims where needed.
Detect and escalate FWA cases to the concerned teams in line with Claims handling guidelines.

Skills

Good English Skills
Good Communication Skills
Clinical Experience
Medical Insurance Experience (Preferable)

Education MBBS (Bachelor of Medicine & Surgery) Job Location: Jeddah, Saudi Arabia Job Role: Medical, Healthcare, and Nursing #J-18808-Ljbffr

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الشركة المعلنة عن الوظيفة

Almajdouie

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Manager - Medical Claims Operations (Pipeline)

تفاصيل الوظيفة

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الشركة المعلنة عن الوظيفة

Almajdouie

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تفاصيل الوظيفة

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الشركة المعلنة عن الوظيفة

Almajdouie

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