Medical Claims Specialist

1 week 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 be responsible for assessing and approving medical claims for outpatient pre-certification.

Key Responsibilities:
  1. Claim Assessment: Evaluate medical claims for outpatient pre-certification, ensuring compliance with policy conditions and guidelines.
  2. Treatment Plan Review: Assess the necessity of treatment plans for patients, making informed decisions based on medical evidence.
  3. Claim Approval: Input approvals for verbal and written claims, ensuring timely and accurate processing.
  4. Policy Adherence: Make decisions based on policy conditions, ensuring adherence to company guidelines.
  5. High-Cost Claim Evaluation: Assess high-cost claims, providing decisions on complicated cases while ensuring customer satisfaction.
  6. Feedback and Communication: Provide clear feedback to the call center team, ensuring effective communication and query resolution.
  7. Client Communication: Explain declined medical claims to clients, ensuring transparency and understanding.
  8. Workflow Coordination: Coordinate workflow, meeting deadlines and productivity targets.
  9. Claim Eligibility Evaluation: Evaluate claims for eligibility, ensuring accurate processing.
  10. Productivity Targets: Meet daily productivity targets for claims type and tenure, adhering to company standards.
  11. Adjudication: Adjudicate outpatient pre-certification claims on a first-in-first-out basis, ensuring timely processing.
  12. Productivity Metrics: Maintain productivity metrics, achieving 85% TAT within 10 minutes and 98% within the first hour for emergency and VIP cases.
  13. Schedule Adherence: Adhere to schedule and punctuality, ensuring timely completion of tasks.
  14. Decision-Making: Make responsible decisions, considering market practice, policy terms, and customer satisfaction.
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.


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