Medical Claims Manager (Approvals)

Summary:

Medical Claims Manager is responsible for supervising daily work of Medical Claims Department in providing quality service to clients, promptly and effectively according to operations set standards, TAT and SLA in addition to t he position requires the ability to independently plan, schedule, organize and respond appropriately on a variety of subjects and situations. In order to achieve the goals of this position, effective leadership and decision making skills are crucial.

Main Tasks:

- Serve as the acknowledged expert and information source for staff
- Follow medical guidelines, practices and regulator ( AI ) instructions .
- Setting goals and Priorities for medical team and Provide feedback about areas for improvement
- Respond to employee questions / concerns on individual basis as needed
- Conduct and schedule staff development opportunities
- Organized Establishment of effective cost containment plans, Case management and Cost Saving for jumbo cases and high cost management ( referral and special discount )
- Update Network Department with providers having issues with Codes and Price, Referral Matrix and Centers of Excellence
- Raise suspected fraud and abuse provider to Network and Fraud, Waste and Abuse ( FWA ) departments
- Provide accurate analytic Data; insights and recommendations to multiple stakeholders
- Monitor adherence to policies and established procedures
- Meet the qualitative requirements and continuously work to improve quality of approvals.
- Monitoring of the daily dashboard to ensure adherence to SLA, TAT and the productivity
- Assist clients with escalated queries and provide suitable query resolution for other departments
- Ensuring participative leadership and strong communication within the team
- Coaching and team Development with quality assurance and trending
- Regular evaluation and root cause analysis for department enhancement
- Increase automation percentage and accuracy and review the rules

Minimum Requirements:
- Bachelor of Medicine and Bachelor of Surgery MBBS
- 8+ years of experience in a mid-to-large sized organization in the similar role.
- SCFHS
- Typing and communication skills in English & Arabic.
- Physically fit to carry out duties.