Medical Claims Officer

Key Responsibilities 1. Claims Processing & Adjudication

• Review and process outpatient, inpatient, and reimbursement claims.
• Validate claims against policy coverage, exclusions, and limits.
• Ensure completeness of documentation (medical reports, invoices, prescriptions, discharge summaries).
• Validate medical coding (ICD, SBS) and ensure alignment with diagnosis and treatment.
• Assess medical necessity and appropriateness of services.
• Flag suspected over utilization, billing errors, duplications, upcoding, unbundling or inflated charges. and abuse, or fraud cases.

• Adhere to internal policies, SOPs, and regulatory requirements (e.g., CCHI in KSA).
• Apply contract terms (network agreements, tariffs, co-payments, deductibles).

• Support cost-containment initiatives.
• Perform detailed review for high-value claims and agree on deals when applicable.

• Liaise with healthcare providers for missing or unclear information through MCU team.
• Coordinate with medical approvals team when needed.
• Respond to internal queries (customer service, medical network, complaints, finance).

• Process claims within defined SLA timelines.
• Prioritize urgent or high-value claims.
• Maintain productivity and quality benchmarks.

• Identify suspicious claims and elevate as per protocol.
• Support investigations by providing medical insights.

• Bachelor of Science in Medicine, Dental Surgery or equivalent.

• 1-3 years of experience in medical insurance.
• KSA regulatory and market knowledge
• Claims processing and auditing

• Ability to assess medical requests critically and make sound medical and technical decisions based on guidelines.
• Strong attention to detail for accurate documentation and reporting.

• Proficiency in using claims management software and other healthcare IT systems.
• Advanced skills in MS Office (Word, Excel, and PowerPoint) for reporting and documentation.

• Proven ability to handle high volumes of requests efficiently without compromising quality or compliance.
• Meet deadlines for all assigned tasks.

• Collaborate effectively with internal and external stakeholders.

• Quickly resolves Claims issues with professionalism and accuracy.

• Strong understanding of medical adjudication processes, medical terminology, and insurance claims.
• Ability to make accurate, timely decisions based on medical guidelines and claims software.
• Attention to detail and strong organizational skills to ensure all claims are processed efficiently.

• Fluency in English/Arabic