• Review medical claims for accuracy, completeness, and medical necessity.

• Assess diagnosis, treatment plans, investigations, and procedures against clinical guidelines.

• Verify insurance coverage and policy eligibility.

• Approve, reject, or recommend modifications to medical claims based on medical justification.

• Review pre-authorizations and post-treatment claims when required.

• Communicate with treating physicians to obtain additional clinical information when necessary.

• Coordinate with insurance companies regarding claim approvals and medical inquiries.

• Ensure compliance with hospital policies, insurance regulations, and clinical standards.

• Identify inappropriate billing or potential fraud and report findings.

• Maintain complete and accurate documentation of claim reviews.

• Prepare medical review reports and performance statistics.

• Participate in quality improvement initiatives related to claims management.

• Perform any other duties assigned by the direct manager.

Requirements

Education

• Bachelor's Degree in Medicine and Surgery (MBBS/MBBCh).

• Valid medical license.

Experience

• 2–4 years of clinical experience.

• Previous experience in Medical Claims, Utilization Review, Health Insurance, or Medical Approvals is a Must.

Technical Skills

• Knowledge of medical coding concepts (ICD/CPT is an advantage).

• Understanding of health insurance policies and claims processing.

• Familiarity with Hospital Information Systems (HIS).

• Good Microsoft Office skills.

Competencies

• Strong clinical judgement.

• Analytical and critical thinking.

• Attention to detail.

• Decision-making skills.

• Communication and negotiation skills.

• Problem-solving ability.

• Time management.

• Integrity and confidentiality.

• Ability to work under pressure.

Languages

• Arabic: Native.

• English: Good command (written and spoken).