Manager Medical Claims

📣 إعلان

منذ ساعة واحدة تقريباً

	نوع العقد	دوام كامل
	طبيعة الوظيفة	بالموقع
	الموقع	الرياض

وصف الوظيفة

About the Role

Tawuniya is seeking a Manager Medical Claims to join their team in Riyadh, Saudi Arabia. This full-time role involves processing and evaluating medical claims efficiently and accurately, ensuring compliance with coverage scopes, provider contracts, and regulatory requirements while maintaining quality and turnaround-time standards.

Key Responsibilities

Apply Claims Department policies, procedures, and quality standards consistently.
Process assigned claims efficiently, adhering to agreed turnaround times (TAT) and Service Level Agreements (SLA) for all batches from creation to closing.
Manage internal and external email communications professionally, following established email etiquette and SLAs.
Ensure all adjudication decisions comply with CCHI regulations, Insurance Authority requirements, and Tawuniya's internal policies.
Review internal quality-review findings, address identified gaps, and implement agreed corrective actions.
Contribute to the training and development of claims staff by sharing medical knowledge and processing guidelines.
Provide structured feedback on system limitations, operational process gaps, and opportunities for improvement.
Support data-driven claims management and healthcare value initiatives, including VBHC, DRG, and PHM, to identify utilization trends, improve care quality and appropriateness, optimize healthcare costs, and support continuous improvement.
Provide medical claims data analysis to identify utilization patterns, cost drivers, abnormal trends, and potential areas of leakage or overutilization.
Deliver assigned Key Performance Indicators (KPIs) and drive continuous improvement through quarterly Kaizen initiatives and One Point Lessons (OPLs).
Pursue individual technical, personal, and medical skills development in line with the agreed capability-building plan.