JOB PURPOSE
The Jobholder serves providers and insurance companies by determining requirements, answering inquiries, resolving problems, fulfilling requests and maintaining database. He / She should provide accurate and relevant medical coverage details, maintain pre-approvals and claims processing and adjudication cycle within NHS software systems as per the defined terms and policies of the organization; He/ She will be guided by the regulations laid down by the regulatory authorities such as MOH, DHA or others.
2. RESPONSIBILITIES AND DUTIES
§ To issue online and verbal authorizations based upon member coverage & medical justification.
§ To assist queries from providers and payers via phone calls or e-mails
§ To maintain files for authorizations and other reports.
§ Assessing and processing claims in line with the policy coverage and medical necessity.
§ Be fully versed with medical insurance policies for various groups / beneficiaries.
§ Might be required to assist in training colleagues and sharing knowledge.
§ Able to accurately assess eligibility within the UAE (HAAD and DHA) guidelines as well as policy boundaries.
§ Monitoring and maintaining the claims processing and adjudicating cycle in NHS 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 NHS 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.
§ Ensure adherence to the predefined TATs for claims and pre-approvals
§ Achieving required processing targets assigned by the team leader on daily, weekly and monthly basis.
§ Monitor the qualitative and quantitative measures for claims & pre-approvals.
§ Ensure compliance to any changes in terms of system parameters or process.
3. KNOWLEDGE, SKILLS AND EXPERIENCE
§ University degree in any discipline of Medical/Para-medical specialization from a reputable university.
§ Healthcare/Hospital experience for 1-2 years, in departments such as Surgery, ICU or GP, is required.
§ 1 - 2 years of work experience in the Insurance industry is preferable but not mandatory.
§ Excellent oral and written communication skills.
§ Must be computer literate.
§ Excellent command of the English language, Arabic is a definite plus.
§ Should be a team player with an aptitude for customer service. Must be service oriented.
§ Highly decisive with outstanding logic and reasoning skills.
§ Candidate must be tactful and discrete while dealing with Providers or Payers; must be able to handle confidential information.
§ Ability to work under pressure and meet tight deadlines and varying work-schedules.
Job Types: Full-time, Permanent