Medical Officer

1 week ago


Dubai, Dubai, United Arab Emirates TPA Full time

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 daycare and inpatient cases as per medical justification and policy coverage.
  • Issuing daycare and inpatient cases within AED 15,000.00 for medically justified cases in line with the policy.
  • Escalate and confirm greyarea 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 daycare and Inpatient 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 daycare and inpatient cases to be signed by Chief Medical Officer.
  • Conformity of assessment for the prescribed tests/medications/investigations/clinical procedures
  • Issuing daycare and Inpatient 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 teamleader on daily, weekly and monthly basis.
  • Monitor the qualitative and quantitative measures for IPclaims & preapprovals.
  • 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)
years' experience in the healthcare industry/hospitals is mandatory

  • Basic Industry knowledge (healthcare/insurance) is a plus.
  • Should be a teamplayer 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
  • Ability to work under pressure and meet tight deadlines and varying workschedules

Job Types:
Full-time, Permanent

Pay:
AED9, AED10,000.00 per month

Education:

  • Bachelor's (preferred)

Experience:

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

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