Job Description

Duties and Responsibilities:

Claims Processing Oversight

• Support the Manager in supervising daily claims / batch intake, validation, adjudication, and settlement activities.
• Ensure compliance with Nphies e-claims standards, coding standards, MDS and timeline specified per regulations.
• Monitor turnaround times (TAT) to meet internal and external service-level agreements (SLAs).

Quality Assurance & Compliance

• Assist in implementing internal controls to ensure claims accuracy and prevent fraud, waste, and abuse.
• Coordinate with internal audit and compliance teams to maintain adherence to CCHI guidelines and regulatory directives.
• Contribute to training programs for staff and providers on correct claims submission and reconciliation processes.

Discrepancy Resolution

• Oversee investigation of claim discrepancies, rejections, and denials, and ensure timely resolution.
• Support communication with healthcare providers, external and internal teams / stakeholders to address recurring issues.
• Escalate unresolved or high-impact discrepancies to the Senior Claims Manager with recommended solutions.

Stakeholder Management

• Act as deputy contact point for healthcare providers, external and internal stakeholders and claims staff.
• Provide guidance to healthcare providers on claims processing requirements and Nphies compliance.
• Participate in regular meetings with hospitals, clinics, and pharmacies to strengthen provider relations.

Reporting & Continuous Improvement

• Prepare operational dashboards and performance reports for management review.
• Support process re-engineering projects to reduce rejections and enhance claims accuracy.

People Management & Performance

This role is critical for the day-to-day leadership and performance development of the claims processing team, which is vital for a Tier 1 insurance company’s operational excellence.

• Team Oversight & Support: Supports the Manager in supervising daily claims intake, validation, adjudication, and settlement activities.
• Training & Development: Contribute to training programs for staff and providers on correct claims submission and reconciliation processes.
• Performance Management (Tactical): Oversee investigation of claim discrepancies, rejections, and denials, and ensure timely resolution. Identify trends in denials and contribute to corrective action plans.
• Risk & Compliance Culture: Acts with due diligence to safeguard company interests. Maintain highest level of confidentiality.

KPI Monitoring, Reporting, and Continuous Improvement

This area transforms raw claims data into actionable insights for management, a non-negotiable for a large insurer focused on efficiency and cost control.

• KPI Monitoring: Monitor turnaround times (TAT) to meet service-level agreements (SLAs). Support the oversight… of the end-to-end claims processing management cycle. TAT/SLA Compliance: Time taken from claim receipt to final settlement. First-Pass Ratio (FPR): Percentage of claims processed without manual intervention or rejection.
• Reporting & Analysis: operational dashboards and performance reports for management review. Identify trends in denials.
• Continuous Improvement: process re-engineering projects to reduce rejections and enhance claims accuracy.

Education:

Bachelor’s degree in Medicine / Pharmacy, Healthcare Administration, Business Administration or Health Informatics.

Experience:

• Hands-on experience in Medical Claims Processing domain (3–5 years minimum)
• Healthcare Insurance & Regulatory Compliance (5+ years preferred)
• Understanding of Medical Claims Processing

Personal Attributes / Skills:

• Integrity & Ethical Mindset – Strong moral principles to handle sensitive financial and healthcare data responsibly.
• Attention to Detail – Ability to spot anomalies, inconsistencies, and patterns in data.
• Analytical Thinking – Logical approach to problem-solving and decision-making.
• Critical Thinking – Evaluating evidence to determine fraud risks and compliance gaps.
• Persistence & Patience – Fraud investigations and reconciliations can be complex and time-consuming.
• Communication Skills – Clear reporting of findings to internal teams, auditors, and regulators.
• Confidentiality & Discretion – Handling sensitive patient and financial information with care.
• Adaptability – Keeping up with evolving fraud schemes and regulatory changes.

Others:

• Fluency in Arabic language, working knowledge of the English language is an advantage.
• Proficiency in using Microsoft Office applications and database management.
• Ability to work independently and as part of a team to achieve network management goals.