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Medical Claims Senior Assessor

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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.

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