RCM Medical Claims Specialist

About My Clinic KSA

My Clinic KSA, established in 2017, is a leading multispecialty outpatient care provider in Saudi Arabia. The organization is dedicated to helping individuals achieve longer, healthier, and happier lives, driven by core values of care, collaboration, ambition, and responsibility. As My Clinic KSA expands, it seeks professionals who align with its vision and values.

The Role of RCM Medical Claims Specialist

My Clinic KSA is seeking an RCM Medical Claims Specialist to join its team in Jeddah, Makkah, Saudi Arabia. This full-time role is integral to the Medical Operations function, focusing on the clinical review and validation of insurance claims prior to submission. The specialist ensures medical necessity, documentation completeness, consistency in coding and services, and compliance with payer and Revenue Cycle Management (RCM) requirements. The position supports the increasing volume of monthly claims and new branch expansions by proactively identifying claim risks and coordinating corrections to enhance clean-claim quality, thereby reducing rejections and write-offs.

Key Responsibilities

• Perform detailed clinical review and validation of medical claims before submission to ensure accuracy, completeness, and readiness.
• Validate medical necessity, diagnoses, investigations, procedures, medications, and other billed services against patient medical records and documented care plans.
• Review claim documentation for completeness and consistency, including physician notes, reports, orders, results, supporting documents, and required attachments.
• Identify clinical, coding, documentation, utilization, duplicate-service, unbundling, approval, eligibility, and payer-rule risks that could lead to rejection, deduction, or write-off.
• Ensure consistency between services rendered, approvals obtained, quantities/sessions, diagnosis and procedure coding, and billed claim lines before final submission.
• Coordinate with physicians, Medical Operations, Pre-Authorization, Claims/Billing, Operations, and other relevant teams to clarify discrepancies and complete necessary corrections within submission timelines.
• Review rejected or deducted claims from a clinical perspective, identify root causes, support rework/resubmission where applicable, and recommend corrective and preventive actions to reduce recurrence.
• Monitor recurring claim issues and rejection trends, provide feedback to the Medical Operations Lead, and support targeted education or process improvements for clinical and operational teams.
• Support claim quality audits, payer queries, reconciliation activities, and documentation requests, including the preparation of clinical justification and supporting evidence when required.
• Support new branches, new services, payer activations, and increasing claim volumes by applying standardized medical claim validation processes and escalating material risks promptly.
• Perform other professional duties as assigned by the Line Manager.

Qualifications and Experience

• Education: Bachelor’s degree in medicine (MBBS/MD), Pharm D, Biology, Microbiology, Chemistry, or an equivalent medical/clinical qualification.
• Experience: A minimum of 2 years of experience, with 2-5 years preferred, in healthcare, medical insurance, claims review, utilization review, or Revenue Cycle Management. Experience in a high-volume outpatient setting is preferred.
• License (Optional): Valid Saudi Commission for Health Specialties (SCFHS) classification/registration, where applicable to the professional qualification.
• Professional Certification (Optional): Certification or formal training in medical coding, health insurance, claims management, or Revenue Cycle Management is preferred.

Work Environment

This is a full-time position based in Jeddah, Makkah, Saudi Arabia, within a dynamic and growing healthcare environment focused on patient care and operational excellence.

Application Process

Candidates who meet the specified qualifications and are interested in contributing to a leading healthcare provider are encouraged to apply. Salary details will be discussed during the interview process.