Medical Claims Operations - Jeddah, المملكة العربية السعودية - Bupa Arabia
وصف
Role Purpose
To be fully trained and aware of claims handling process including adjudication & fraud, waste and abuse management. Moreover, ensuring that daily assigned tasks are completed withing the specified time frame in line with Bupa's values.
Key Accountabilities
- Process all the daily batches of claims assigned in line with medical policy and Outpatient adjudication guidelines while using his/her medical background in conjunction with the instructed guidelines.
- Assures that each OP claim has been processed as per the checklist of steps involving checking of physical claim (or scanned image on the document management system), and cross checking with the electronic claims data on Edge, and reflecting the right decision for every claim on the operations system.
- Achieve daily target in terms number of claims processed.
- To achieve required quality through achieving at least 95% accuracy level on monthly quality audits, in order to maintain the quality standard set for the job.
- Makes sound medical decisions that minimize the opportunity to be challenged by providers, and consults with the medical manager where in doubt.
- Reports abnormal trends of provider practice for adjudicated claims where needed.
- Detects and escalates FWA cases to the concerned teams in line with Claims handling guidelines.
Skills:
- Fresh Graduate.
- Ability to conduct business in English language.
Education:
Bachelor's degree in pharmacy
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