Senior Medical Insurance Specialist📣 إعلان

About the Role

Makkah Medical Center Hospital is seeking a Senior Medical Insurance Specialist for a full-time position in Makkah. This role is critical for optimizing the medical insurance process, focusing on proactive measures to prevent claim denials and improve approval efficiency. The specialist will be responsible for strengthening pre-authorization submissions, reducing approval turnaround times, and effectively managing pending queues to ensure smooth patient admissions and scheduled procedures. When denials occur, the role requires skilled appeal writing to overturn decisions and ensure financial accuracy.

Key Responsibilities

• Verify patient eligibility and coverage before service.
• Prepare pre-authorization requests with robust clinical justification to achieve first-time approval.
• Follow up on pending approvals and escalate delays that hinder admissions or scheduled procedures.
• Handle urgent and emergency approvals efficiently within payer timeframes.
• Take ownership of the first-time approval rate and approval turnaround time as key performance metrics.
• Conduct claim reviews, ensure coding accuracy, and submit clean claims.
• Manage denials through root-cause analysis, effective appeals, and resubmission.
• Reconcile outstanding balances with payers and Third-Party Administrators (TPAs).
• Provide monthly reporting on rejection rates, approval turnaround, and Days in Accounts Receivable (AR).

Qualifications and Experience

• A minimum of 8 years of experience covering both approvals and claims in a hospital or polyclinic setting.
• Demonstrated track record of measurable results; candidates should be prepared to articulate their first-time approval rate and rejection rate, both before and after their involvement.
• Strong command of ICD-10 and CPT coding, with the ability to independently identify coding gaps.
• Deep familiarity with CCHI regulations, NPHIES, payer contracts, and medical necessity criteria.
• Advanced Excel proficiency and hands-on experience with Hospital Information Systems (HIS) and payer portals.
• Professional proficiency in both Arabic and English, as the role requires writing justifications and appeals in both languages.

Preferred Qualifications

• Coding certification (CPC / CCS).
• Prior experience on the payer side reviewing approvals.

Work Environment and Application

This is a full-time position based at Makkah Medical Center Hospital in Makkah. We invite qualified candidates who meet the specified requirements to apply for this role.