Manager - Medical Claims

Job Purpose:

Process and evaluate all assigned medical claims efficiently and accurately, in accordance with the scope of coverage, provider contracts, and CHI/ IA regulatory requirements, while consistently meeting quality and turnaround-time standards.

Key Accountabilities:

• Apply Claims Department policies, procedures, and quality standards.

• Process assigned claims with efficiency, maintaining agreed TAT and SLA for all batches, from creation through closing.

• Handle internal and external email communications professionally, following email etiquette and agreed SLAs.

• Ensure all adjudication decisions comply with CCHI regulations, Insurance Authority requirements, and Tawuniya internal policy.

• Review internal quality-review findings, address identified gaps, and implement agreed corrective actions.

• Contribute to the training and development of claims staff by sharing medical knowledge and processing guidelines.

• Provide structured feedback on system limitations, operational process gaps, and improvement opportunities.

• Support data-driven claims management and healthcare value initiatives, including VBHC, DRG and PHM to identify utilization trends, improve quality and appropriateness of care, optimize healthcare costs and support continuous improvement.

• Provide medical claims data analysis to identify utilization patterns, cost drivers, abnormal trends and potential areas of leakage or overutilization.

• Deliver assigned KPIs and drive continuous improvement through quarterly Kaizen initiatives and OPLs.

• Pursue individual technical, personal, and medical skills development against the agreed capability-building plan.

Qualifications, Experience & Skills:

• University degree in MBBS; A Master degree is a plus.

Minimum Experience:

• 1 year of experience in medical field.

• 4 - 5 years of experience in insurance industry preferably in medical claims.