Medical Claims Processor - Nurse/ Doctor

At Damana Insurance, we are looking for a nurse/doctor by education with experience in medical coding to join our TPA in Bahrain as a Medical Claims Processor.

The Medical Claims Processor is responsible for claims processing of UAE and non-UAE markets. This includes electronic claims, manual paper claims and reimbursement claims. As a Claims Processor, you will be required to analyze a claim based on policy conditions, regulatory requirements, international medical guidelines and internal process and procedures.

Key Responsibilities:

• Data entry / Medical review claims that are assigned in CMS at batch level or claim level as the case may be.
• Adjudicate each claim and associated services based on coding rule (UAE market) and policy conditions that includes system driven eligibility checks, coding checks and perform medical investigations.
• Follow pre-approval protocols as per provider handbook.
• Adhere to system driven price list information for financial accuracy of the claims.
• Approve up to the authority matrix.
• Coordinate with pre-approval team and network team on a case-by-case manner where relevant for the claims adjudication.
• Coordinate with providers in explaining the rejections on claims.
• Assist Team Leader and Operations Manager in enhancing and developing the process and system.
• Adhere to the contents of the Operating Procedures Manual (OPM) and the Company’s overall procedures and policies.
• Miscellaneous tasks within the scope of work, as assigned by the direct manager.

Qualifications:

• Bachelor's degree in nursing or MBBS
• Experience and certification in medical coding is a must.
• 1 – 2 years' experience in health insurance field preferred.