Medical Claims Senior Assessor

Key responsibilities/What you do:

• Review and assess medical claims for both inpatient and outpatient services to determine coverage eligibility and compliance with policy terms.
• Validate Diagnosis-Related Group (DRG) coding for inpatient admissions using ICD-10-CM and CPT standards, ensuring alignment with clinical documentation.
• Apply thorough knowledge of UAE healthcare billing regulations, including DHA, DOH, and MOH guidelines, to ensure claims meet local compliance standards.
• Identify and rectify incomplete or inaccurate claim submissions.
• Ensure all required documentation is present and properly coded aligning with policy guidelines.
• Notify payers regarding claims that exceed predefined financial thresholds, ensuring timely communication and resolution.
• Track and maintain both quantitative (volume) and qualitative (accuracy) metrics for claims processing.
• Achieve assigned daily processing targets while maintaining high levels of accuracy and efficiency.
• Collaborate with internal departments to resolve claim-related queries.
• Perform other responsibilities as assigned by the department lead, in line with the scope of the role.