Medical Officer - (MBBS) with insurance TPA experience

RESPONSIBILITIES AND DUTIES

Research and follow up on Medical Treatment patterns and conduct utilization reviews for Beneficiaries (Policyholders) & Medical Network providers, Quality control by:

§ Being available (On call) 24 hours a day for Claim Centre Officers queries relating to in-patient claims.

§ Assess day-care and in-patient cases as per medical justification and policy coverage.

§ Issuing day-care and in-patient cases within AED 15,000.00 for medically justified cases in line with the policy.

§ Escalate and confirm grey-area cases. Confirming of exclusions of borderline cases OP/IP.

§ Assists CC officers and supervisors in claims adjudication cases as needed.

§ Sending request of confirmation and notification to corresponding payers as needed.

§ Responding to payer's queries in relation to day-care and In-patient cases.

§ Responding to the payers request for advice on coverage of cases.

§ Monitor Claims cost as per internal guidelines.

§ Rejecting medically unjustified and policy wise excluded day-care and in-patient cases to be signed by Chief Medical Officer.

§ Conformity of assessment for the prescribed tests/medications/investigations/clinical procedures

§ Issuing day-care and In-patient cases Reimbursement Approval in line with medical and policy coverage.

§ Contacting provider for queries and clarifications.

§ Doing clinical discussion directly with the network's doctor as needed.

§ Seeking verbal clinical opinion from Network's doctor as needed.

§ Document and report to CC Supervisor, Assistant Manager and Manager any suspected fraud cases.

§ Monitoring and maintaining the claims processing and adjudicating cycle in operational software system as per the defined terms and policy of the organization.

§ Establishing strategies and implementing effective parameters for solving all possible queries within the team.

§ Taking a lead role in assuring that the assigned tasks to the team are completed within the allocated time frame.

§ Ensures the proper communication and implementation of new formats, training and processing rules.

§ Entering and processing/ adjudicating claims in operational software system as per the terms and policy of the organization.

§ Taking initiatives to maximize team efficiency.

§ Maintaining both qualitative and quantitative claims measures.

§ Achieving required processing targets assigned by the team-leader on daily, weekly and monthly basis.

§ Monitor the qualitative and quantitative measures for IP-claims & pre-approvals.

§ Ensure compliance to any changes in terms of system parameters or process.

§ Assisting the CC Supervisors / Asst. Manager and Managers as needed.

§ Any additional duties commensurate with your position as may be assigned to you from time to time by the Company.

3. KNOWLEDGE, SKILLS AND EXPERIENCE

§ Medical Doctor (MBBS degree/ MD degree)

§ 2 - 3 years’ experience in the healthcare industry/hospitals is mandatory

§ Basic Industry knowledge (healthcare/insurance) is a plus.

§ Should be a team-player with an aptitude for customer service

§ Must be service oriented

§ Highly decisive with outstanding logic and reasoning skills

§ Excellent oral and written communication skills

§ Must be computer literate

§ Excellent command of the English language, Arabic is a plus

§ Candidate must be tactful and discrete when dealing with clients and must be able to handle confidential information

§ Ability to work under pressure and meet tight deadlines and varying work-schedules

Job Types: Full-time, Permanent

Pay: AED9,000.00 - AED10,000.00 per month

Education:

• Bachelor's (Preferred)

Experience:

• Hospital: 2 years (Preferred)
• Medical Insurance: 1 year (Preferred)