The job holder is responsible to supervise the Reimbursement claims team, monitor output levels, assist processing medical claims in a timely efficient manner and has an overall responsibility of the proper evaluation, processing, auditing and reporting of outpatient reimbursement claims.

Key Job accountabilities are as follows:

• Supervise and monitor the daily target of the reimbursement team, TAT of Reimbursement claims, Quality of processing, and other Key performance indicators set by the management.
• Ensure accurate application of applicable rates for reimbursement according to the Network, schedule of benefits, correct allocation of benefits, collection of deductibles/copayments, observance of policy limits and adherence to claims submission protocols.
• Data entry and adjudication of Reimbursement claims accurately
• Forward approved claims once processed to PICs for their acknowledgment.
• Forward Electronic bordereau of the E- claims to the payers to inform them of approved claims and settlement amounts
• Send weekly and monthly processing reports to clients for their records.
• Answering provider, insured members and PICs queries via phone calls and emails, regarding claims processing, coverage limit inquires and any other inquiries to provide them with clarifications where needed.
• Monitor the performance of the team members and provide them the required training in order to improve their technical, medical, insurance skills and knowledge, improve the quality and efficiency of performance, enable them to fulfill special tasks and achieve set targets, daily duties and responsibilities.
• Train new hire processors or current processors where needed to insure they are capable of doing their job.
• Take a leading role in developing, updating and implementing guidelines for processing and reporting of claims.
• Review and audit the reimbursement claims processed by following the auditing criteria, guidelines and applying the high costs authority matrix when needed.
• Coordinate with the Quality Assurance  Department to ensure best quality level of claims processing by ensuring error corrections and error rates
• Manage holidays, leaves and monitor attendance so as to keep the department functioning in its full performance capacity.
• Report Fraud and abuse cases.
• Organize, attend and document meetings with internal and external groups.
• Consistently, efficiently and effectively work to achieve the daily targets and the initiatives.
• Ensure that the company policies and procedures are followed by the reimbursement claims team.
• Ensure that business decisions and processes are documented in a professional way and the communication requirements are being adhered to in a timely manner.
• Ensure that the team delivers high quality of customer service and respects medical and work ethics at all times.
• Conduct training sessions for PICs/Brokers/Insured Groups.

The job holder is responsible to supervise the production team members, the functionality relating to policy issuance and card issuance and create benefits / plans in line with client requirements for Health Insurance. Bring innovation and problem solving skills to stand ahead of the market standard and expectation.

• Enrollments & Policy Issuance
•  Ensure enrollments and policy issuances are delivered on agreed turnaround times.
• Card issuance & Policy Documentation Conduct preliminary checks on all information received from the PIC's are in line with production department's guidelines.
•  Assist in processing and issuing of policy in MedNeXt system based on the premiums and loadings received from PICs.
• Supervise card issuance process and policy documents such as Policy Wordings, Beneficiary User's Guide, Policy Schedules and Request Forms sent to relevant PICs.
• Creating card layouts and designs as per policy coverage
• Benefits and Plan Creation
• Create benefits / plans and conduct quality audit on accuracy.
• Assist and monitor in computing policies and benefits / plan creation process for better accuracy.
• Update internal departments about the New Policy for any substandard conditions.
• Maintain reinsurance data in the system such as reinsurer, reinsurance account configuration, reinsurance share and etc.
• Quality Checks
• Review and validate computed premium and benefits in order to make sure calculations are in line with quotation.
• Business Correspondence
• Respond to business queries from PICs / Clients effectively and efficiently.
• Production Trainings
•  Train new staff on Production Department's policies & procedures and use of MedNext system tools.
• Business Reporting
•  Prepare monthly activity reports and statistical data for management's review and information.
• Consolidate periodical Reinsurance Bordereau on premium and claims calculations between the insurer and reinsurer parties.

• Minimum Qualifications:
•   Bachelors Degree in Mathematics /Physics / Economics background. Medical background would be added advantage.

• Minimum Experience:
• Minimum of 3 year experience in Claims Management, Medical Underwriting in financial services industry or TPA/MSO Company

• Job-Specific Knowledge & Skills:
• Excellent knowledge of Advanced Excel Skills and MS Office.
• Knowledge related to medical terminology and local health insurance sector

• Required Competencies:
• Good interpersonal and communication skills
•  Analytical approach to problem solving
• Ability to operate effectively with people at all levels of the business
• Team Player

The job holder is responsible to assist the Team Leader- Provider Contracting and Network Manager in the development of the healthcare service provider network, in line with the business plan.

Key accountabilities;

•  Identify sub-categories of providers and preferred providers through Provider Profiling analysis, to create distinctive network advantages for MedNet
• Be responsible for the contracting and re - contracting process and negotiate with the healthcare service providers within  corporate guidelines to ensure all services provided are cost effective and in accord with quality standards
•  Conduct presentations and trainings for appointed healthcare provider staff on managed care concepts and provide updates on all related procedures in order to ensure awareness of MedNet service requirements and policies across the network
•  Review policy manual and network agreements on an on-going basis and provide suitable recommendations
• Support the Team Leader / Manager in the implementation of quality assurance programs in order to maintain standards of quality and minimize fraudulent cases
• Develop and maintain monthly statistical reports to facilitate benchmarking and performance management of network operations for management decision-making
• Update MedNeXt with data relating to addresses, discounts, creation of new codes, specialties, etc. on a periodic basis
• Prepare quarterly network newsletters intended for insured members, insurance companies and intermediaries

•  Diploma or Bachelor Degree in Medicine, Hospital Administration, related healthcare sciences (Physiotherapy, Nursing, Radiology or Laboratory technician) or similar qualification

• 2 - 3 years of experience in a provider contracting role in TPA / medical insurance sector preferably in the Gulf region

• Good interpersonal skills and ability to communicate clearly and effectively with internal and external clients across all levels, with fluency in business English (written and spoken); Arabic would be an advantage

• UAE Driving License is mandatory

•  Industry knowledge related to local healthcare services system will be an added advantage

Systems Engineer is accountable for all onsite service and support needs of internal users pertaining to technology, such as workstations, servers, printers, networks, and vendor specific hardware and software and maintain the computer networking system by tracking server activity, perform upgrades of software, maintain computer hardware, address technical issues under the supervision of direct superior and improve overall operating efficiency by periodic evaluations on system network functions.

Server Administration & Maintenance:

• Monitor server activities to ensure computer networks are run efficiently.

• Manage all network hardware and equipment, including routers, switches, hubs, and UPSs.

• Perform server upgrades, maintenance fixes, vendor-supplied patches and act as a point of contact for server related issues to resolve customer complaints.

• Recommend and execute modifications to server environment in order to improve reliability, and performance.

 Programming

•  Facilitate program designing process and identify project limitations, capabilities, performance requirements and interfaces.

• Test software applications and systems and recommend suitable modifications for existing in-house software programmes in order to improve performance.

• Identify and analyze user needs in line with software requirements to determine feasibility of design within time and cost constraints.

• Coordinate software system installation and monitor performance standards to ensure specifications are met.

 Data Analysis

•  Store, retrieve, and manipulate data for analysis of system capabilities and requirements.

Data Security and Assurance

• Update and administer firewalls, anti-virus, anti-spyware software setup to maintain data security.

• Regular checkups on unwanted software, hardware installations, viruses on Servers, Patches, hot fixes and record the findings for future references.

 Help Desk

• Monitor help desk database and respond to help desk tickets in a timely manner.

System Configuration & Recovery Procedures

• Perform file system configuration and management and perform server backups and recovery procedures.

IT Support & Training

• Provide required IT support and training on user requirements to smoothen the operational workflow.
• Develop and maintain training materials and server documentation.

IT Research and Reports

• Conduct research on server hardware, software, and protocols in support of procurement and development efforts.
•  Create manuals and detailed sets of instructions, departmental reports on a periodic basis.

Minimum Qualifications:

• Diploma  or bachelors Degree in IT field

Minimum Experience:

• One year of experience in server administration in IT Industry.

Job-Specific Knowledge & Skills:

• Knowledge in Computer Programming (languages such as – PHP or Asp.net along with HTML, CSS, Ajax etc.)
• Knowledge of Server (Windows, Exchange, Linux) Administration
• Technical Awareness on matching resources to technical issues appropriately

The position exists within our Medical Call Center that runs 24X7.

Evaluate claims (Network & Direct) and provide authorizations for insured members (in-patient & outpatient).

Handle calls relating to medical cases efficiently.

Assess risk exposure of members in line with medical underwriting policies.

Manage queries from providers, Insurance Companies and insured members relating to claims processing, evaluation and administration.

Provide medical guidance to the Claims Department staff and assistance in ICD coding.

Deliver excellent customer service to Insurance Companies and insured members with a view of achieving maximum client satisfaction.

Client Management / attending hospital visits to investigate on claims in order to minimize fraud and abuse.

Compile data and prepare monthly statistical reports to monitor departmental performance and medical trends.

 University degree in MBBS.

Fresh Graduates or candidates with 1- 2 years of experience in Medical Claims Evaluation preferably from TPA / MSO organization in Insurance sector.

Knowledge of health insurance would be an advantage.

Effective interpersonal and communication skills to manage client expectations, both internal and external with fluency in business English (written and spoken); Arabic would be an advantage

Team player, motivated, dependable and open-minded.

Assertive, reliable and ability to work under strict deadlines.

Cross-cultural competence, willingness to work on shift basis.

• Processing claim forms, adjudicate for provision of deductibles, co-pays, co-insurance maximums and provider settlements.

• Entering claims data into the system.

• Attending to queries from Members / PICs / Providers and resolving problems that results from claim settlement.

• Performing audit of randomly selected claims to ensure quality processing and detect any frauds.

• Researching claim overpayments and request funds.

• Following adjudication policies and procedures to make sure proper payment of claims.

• Providing timely and quality customer service to members, providers, and other insurance companies .

• Maintaining and preparing departmental of records.

• Diploma in business management or related degree with a Diploma in any of the Para-Medical Courses.

• Minimum one year of experience in claims management in Insurance industry or TPA Company.

• Basic knowledge of relational databases and excellent knowledge of MS Office.