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Medical Claims Officer

2 months ago

Dubai, Dubai, United Arab Emirates Allianz Partners Full time
Job Summary:

We are seeking a highly skilled Medical Claims Officer to join our team at Allianz Partners. As a Medical Claims Officer, you will play a critical role in ensuring the smooth processing of medical claims for our clients.

Key Responsibilities:
  1. Claims Assessment: Assess and evaluate medical claims to determine their validity and adherence to policy conditions.
  2. Treatment Plan Review: Review treatment plans to ensure they are necessary and meet the required standards.
  3. Claims Approval: Approve or deny claims based on policy conditions and medical necessity.
  4. High-Cost Claims: Evaluate high-cost claims and provide decisions on complicated cases.
  5. Client Communication: Provide clear feedback to clients on claim decisions and ensure they understand the reasons for any denied claims.
  6. Workflow Coordination: Coordinate workflow to meet deadlines and ensure timely processing of claims.
  7. Eligibility Evaluation: Evaluate claims for eligibility and ensure they meet the required criteria.
  8. Productivity Targets: Meet daily productivity targets for claims processing and precertification.
  9. Adjudication: Adjudicate outpatient precertification claims on a first-in-first-out basis.
  10. Productivity Metrics: Maintain productivity metrics of 85% in 10 minutes and 98% within the first hour for emergency and VIP cases.
  11. Schedule Adherence: Adhere to schedule and punctuality requirements.
  12. Decision-Making: Make decisions responsibly and in accordance with policy conditions.
  13. High-Cost Claim Evaluation: Evaluate high-cost claims with efficacy and quantity to meet daily targets, ensuring approval for medical conditions according to guidelines and policy terms.
Requirements:
  1. Education: Bachelor of Science degree.
  2. Experience: 2+ years of medical practical experience, preferably with a reputable insurance provider, broker, or TPA.
  3. Skills: Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.