Doctor - Medical Officer - Tpa Insurance

3 weeks ago

Dubai, United Arab Emirates TPA Full time

**Job description**

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

**Job Types**: Full-time, Permanent

Ability to commute/relocate:

- Dubai: Reliably commute or planning to relocate before starting work (required)

**Education**:

- Bachelor's (preferred)

**Job Types**: Full-time, Permanent

Pay: AED9,000.00 - AED10,000.00 per month

**Experience**:

- Hospital: 2 years (preferred)
- Medical Insurance: 2 years (preferred)

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