Manager Medical Claims

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.

Experience Required

Candidates should possess 5-10 years of relevant experience in medical claims processing and management.

Work Environment

This is a full-time position based in Riyadh, Saudi Arabia.