Manager – Medical Claims Operations (Pipeline)

Company: Bupa Arabia –

WebSite: Riyadh, Saudi Arabia

Job Description:**Job Summary:**

The primary responsibility of this role is to ensure the accurate and timely medical and commercial adjudication of assigned provider inpatient and outpatient claims within established timeframes and quality standards. This contributes to the overarching business objective of delivering high-quality claim statements for BUPA.

**Key Responsibilities:**

* Adjudicate daily claim batches in accordance with medical policy and inpatient/outpatient adjudication guidelines, utilizing medical expertise and established protocols to ensure seamless operational efficiency.
* Verify the accuracy and completeness of each claim by comparing physical or scanned claim documents with electronic data in the Edge system, ensuring correct adjudication decisions are reflected in the operational system.
* Maintain a consistent level of productivity by meeting daily claim processing targets.
* Collaborate with the Claims Medical Manager to discuss and resolve complex or high-value claims requiring further clinical consideration.
* Achieve a minimum of 95% accuracy in monthly quality audits to uphold established quality standards.
* Make informed medical decisions that minimize provider challenges, consulting with the Medical Manager as needed to ensure appropriate resolution.
* Identify and report any unusual or suspicious provider billing trends observed during claim adjudication.
* Detect and escalate potential cases of Fraud, Waste, and Abuse (FWA) to the relevant teams, adhering to established claim handling guidelines.

**Required Skills:**

* Proficiency in written and verbal English communication.
* Demonstrated clinical experience.
* Prior experience in medical insurance is desirable.

**Education:**

* MBBS (Bachelor of Medicine & Surgery) or equivalent medical degree.

Skills: