Senior Manager Medical Claims

About the Role

Tawuniya is seeking a Senior Manager Medical Claims to lead its Medical Claims team in Riyadh, Saudi Arabia. This full-time role focuses on ensuring accurate, compliant, and timely claims adjudication while driving continuous improvement and cost optimization initiatives. The Senior Manager will play a key role in strengthening the quality of care and operational performance within the medical claims department.

Role Purpose

The primary purpose of this position is to lead the Medical Claims team in delivering precise and timely claims adjudication. This includes driving continuous improvement, implementing data-driven cost optimization strategies, and advancing value-based healthcare initiatives to enhance both the quality of care and overall operational efficiency.

Key Responsibilities

• Ensure effective implementation and consistent application of Medical Claims Department policies, procedures, work instructions, and quality standards.
• Plan, allocate, and prioritize workloads across the Medical Claims team based on claim volumes, complexity, business priorities, employee capabilities, and available resources to achieve operational targets.
• Manage team performance through clear objective setting, regular monitoring, structured feedback, and timely intervention to address productivity, quality, and turnaround time (TAT) gaps.
• Maintain effective communication with stakeholders to facilitate timely issue resolution, minimize operational disruptions, and ensure continuity of claims processing activities.
• Ensure all adjudication decisions comply with CCHI regulations, Insurance Authority requirements, benefits structures, and Tawuniya internal policies.
• Lead continuous improvement initiatives to address root causes, reduce processing errors, eliminate waste, and enhance team capabilities.
• Coach and provide on-the-job training to team members requiring additional support to achieve defined processing targets.
• Provide structured feedback and recommendations to support system enhancements, process redesign, automation opportunities, and improved claims processing accuracy and efficiency.
• Support data-driven claims management and healthcare value initiatives, including Value-Based Healthcare (VBHC), Diagnosis-Related Group (DRG), and Population Health Management (PHM), to identify utilization trends, improve quality and appropriateness of care, optimize healthcare costs, and support continuous improvement.

Experience Requirements

Candidates for this role should possess 5-10 years of relevant experience in medical claims management or a related field. This experience should demonstrate a strong background in leading teams, implementing operational improvements, and ensuring compliance with regulatory standards.

Work Environment and Location

This is a full-time position based in Riyadh, Saudi Arabia. The role involves leading a dedicated team within Tawuniya's medical claims department, working in a dynamic environment focused on operational excellence and healthcare value.

Application Process

Interested candidates are encouraged to apply. Salary details will be discussed during the interview process.