Job Purpose:
The job holder will be responsible for medical audit, PAR administration, control of fraud / abuse and assurance of customer service. Receive intimation from Provider through over regulatory portal/e-mail (non-network providers) along with relevant medical reports.
Job Responsibilities:
- Coordinate with providers for case management and cost control.
- Ensure appropriate handling of the customer queries and concerns and achieving FTR.
- Ensure adherence to agreed SLAs for OP/IP Adjudications.
- Address client/broker and provider queries.
- Escalate customer issues and concerns where the timely resolution is not being achieved in light of the laid out policy and turn around time.
- Assist in the running of the PAR unit on a daily 24/7 basis.
- Ensure adherence to unit KPIs and internal and external SLAs.
- Assist in implementation of medical pre-approval processes and regulatory guidelines.
- Conduct onsite visits for audit of suspected cases of fraudulent practice by providers and escalate highrisk cases to the FWA and Network teams.
- Review and audit medical approvals and conclude pending approvals.
- Ensure implementation and maintenance of relevant management information systems, quality controls and SOPs.
Qualifications:
- Medically educated and trained with good overall business experience focusing on health insurance.
- Decision making skills to be able to authorize eligible cases.
- Very good communication skills, verbal and written in English (required) and Arabic (preferable).
- IT skills including MS Office suite, health claim system, MIS.
- Medical coding knowledge.
- Business process design, reengineering, optimization and documentation (workflow, process maps).
- Lean, Six Sigma or other performance/quality improvement methodologies.
