Qureos Mentor

MedNet Egypt L.L.C

<div>
 
 
 MedNet Egypt
 
 is one of the leading managed care service organizations that cater to healthcare needs
 
 .
 
 We are looking for skilled
 
 Senior Medical Reviewer &ndash; 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:
 
 
 
 
 
 <ul>
 <li>
 Review, maintain, and optimize FWA, medical, and business requirement rules within the Medical Rule Engine.
 </li>
 <li>
 Manage rule logic related to fraud, abuse, waste detection, clinical appropriateness, benefit coverage, coding, and policy compliance.
 </li>
 <li>
 Conduct end-to-end testing, UAT, and validation of rules, including logic, thresholds, and performance checks.
 </li>
 <li>
 Ensure comprehensive documentation for rule logic, assumptions, testing, approvals, and audit trails.
 </li>
 <li>
 Monitor rule performance using KPIs such as accuracy, hit rate, savings/recovery, and claims correction impact.
 </li>
 <li>
 Identify and implement automation opportunities to improve productivity and reduce manual intervention.
 </li>
 <li>
 Collaborate with FWA, QA, Claims, Approvals, IT, Network, Production, and operational teams on system updates and enhancements.
 </li>
 <li>
 Support calibration of QA and FWA findings and align automation outputs with audit objectives.
 </li>
 <li>
 Coach colleagues on system logic, rule functionality, and automation best practices.
 </li>
 <li>
 Plan, map, review, and quality-check rule data, ensuring data accuracy before system deployment (beta and live).
 </li>
 <li>
 Define and execute testing scenarios and ensure implementation aligns with approved plans and technical developments.
 </li>
 <li>
 Ensure rule maintenance and development comply with governance frameworks and stakeholder communication requirements.
 </li>
 <li>
 Coordinate stakeholder meetings, manage progress and maintenance reporting, and support timely delivery of medical review automation initiatives.
 </li>
 </ul>
 
 
 Your Profile:
 
 
 <ul>
 <li>
 Bachelor&rsquo;s degree in medicine, pharmacy &amp; dentistry or related fields.
 </li>
 <li>
 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.
 </li>
 <li>
 Industry knowledge related to the local health services system is a plus
 </li>
 <li>
 Strong understanding of claim auditing, QA frameworks, and workflows, automation and rules configuration.
 </li>
 <li>
 Strong understanding of rule engines, automation logic, and claims systems.
 </li>
 <li>
 Knowledge of medical coding (ICD, CPT) and clinical/claims workflows
 </li>
 <li>
 Strong analytical thinking and attention to details
 </li>
 <li>
 Strong documentation and communication skills
 </li>
 <li>
 Good command of English and computer literacy
 </li>
 </ul>
 
 
</div>

Senior Medical Reviewer – Rule Engine

<div>
 
 
 MedNet Egypt
 
 is one of the leading managed care service organisations that cater to healthcare needs
 
 .
 
 We are looking for a skilled
 
 Officer - Medical Customer Service
 
 will be responsible for providing exceptional customer service support to customers and/or insured members. Handle high volume of incoming calls, chats and emails inquiries, and complaints, ensuring prompt and effective resolution while maintaining a high level of customer satisfaction.
 
 
 
 
 
 
 Your Job:
 
 
 
 
 
 <ul>
 <li>
 Handle inbound and outbound communication via phone, chat, and email to address customer and member inquiries, complaints, and requests.
 </li>
 <li>
 Deliver high-quality customer service by listening actively, showing empathy, and providing accurate and timely resolutions.
 </li>
 <li>
 Follow standard procedures and company guidelines to resolve issues professionally and consistently.
 </li>
 <li>
 Document all interactions accurately with proper wrap-up notes and logs after each call or chat.
 </li>
 <li>
 Develop in-depth product knowledge, including policies, benefits, terms, and updates to provide accurate information.
 </li>
 <li>
 Support outbound campaigns, including follow-ups, courtesy calls, satisfaction checks, and clarification requests.
 </li>
 <li>
 Collaborate with internal teams and support departments to ensure efficient service delivery and issue resolution.
 </li>
 <li>
 Contribute to a positive team culture, participating in department tasks and fostering continuous improvement.
 </li>
 <li>
 Meet and exceed performance KPIs, such as CSAT, FCR, AHT, and quality assurance scores.
 </li>
 <li>
 Adapt to shift work, including evenings, weekends, and holidays, as per business requirements.
 </li>
 <li>
 Maintain professionalism and resilience in high-pressure situations and when dealing with challenging customers.
 </li>
 <li>
 Comply with internal policies, procedures, and the company&rsquo;s code of conduct at all times.
 </li>
 </ul>
 
 
 
 
 
 
 
 
 Your Profile:
 
 
 
 
 
 <ul>
 <li>
 Bachelor&rsquo;s degree in Business Administration or a related field; medical background is a plus.
 </li>
 <li>
 6 months to 2 years of customer service experience, preferably in a call center or contact center environment.
 </li>
 <li>
 Experience in the healthcare or insurance industry is preferred.
 </li>
 <li>
 Excellent English communication skills, both verbal and written.
 </li>
 <li>
 Strong interpersonal and problem-solving abilities with a customer-first approach.
 </li>
 <li>
 Proficiency in customer service software and tools; computer literacy is required.
 </li>
 <li>
 Ability to handle high call volumes and perform well under pressure.
 </li>
 <li>
 Flexible to work shifts, including evenings, nights, weekends, and public holidays.
 </li>
 <li>
 Empathy, adaptability, and resilience in dynamic, customer-focused environments.
 </li>
 </ul>
 
 
</div>

Medical Customer Service Officer

Join MedNet Egypt L.L.C and explore 2   exciting career opportunities. They're hiring for various roles with options for remote or on-site work. Apply today and become part of their innovative team.

MedNet Egypt L.L.C

About Company

Senior Medical Reviewer – Rule Engine

Medical Customer Service Officer