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Job Description
- Monitors providers billing and utilization behaviors to identify opportunities for improvements in clinical practice and billing
- Provide guidance and expert medical direction to the different departments and units concerned with cost containment (e.g. claims ,approval, provider’s relations, and medical analysis….etc.).
- Investigate and audit medical records within assigned medical providers.
- Set, and continuously update, the criteria for investigation and case auditing in coordination with the relevant department and units.
- Set schedules for routine regular case auditing.
- Ensure Provider Networks to meet customer and business needs through expert knowledge of market providers. ( Ensure Cost effectiveness for Hospital admitted cases ( non PD approved cases )
- Assist and help in medical complex cases to ensure proper medical case management for the insured members and negotiates discounts on same. ( getting marketing insights related to other insurance companies prices, discounts, special benefits )
- Implement strategic action plans & auditing support.
- Identify areas for improvement on and operational effectiveness & efficiency.
- Create extra methods and plans for the unit enhancement and progress
- Responsible for the policies and procedures unit hierarchy
- Represents Med-Right in front of selected cases and providers during admission period
- Revising the patient file and final claim after patient discharge to make sure there are no services/ days not approved by Med-Right team ( Clinical Excellence team & approval team )
- Maintain healthy professional relationship with key persons in assigned providers ( admission office, insurance office, Billing team )
- Ensures compliance with legal and regulatory requirements
- Share our Medical practice guidelines with our providers to improve request processing cycle with less time consumption and better quality
Job Requirements
- Proficient knowledge of the Country’s healthcare Insurance market.
- Preferable Previous Health Insurance Experience
- Bachelor Degree in Medicine and Surgery
- Preferable with post graduate Studies
- Excellent communication and listening skills
- Confidence and presentation skills
- Ability to analyze and research information
- Ability to explain complex information clearly and simply
- Good negotiation skills - Analytic abilities
- Strong problem solving abilities
- Good writing skills, especially for formal letters and email
messages - Good written and spoken languages: Arabic and English
- Expert knowledge of all medical insurance policies, Services pricing fee & billing policies
- Shows good knowledge of Microsoft office applications