• Documents:

1.Be aware of each policy, table of benefit and exception for each client to ensure the proper processing of the claims.

2. Ensure the competence of the documents of each claim according to claims processing procedures and ensuring that all the needed

information is valid.

3. Verify the beneficiary’s information, handle the claim forms and analyzing them starting from arrangement till checking them for validity.

4. Report on daily, weekly and monthly basis the productivity which identifies the work achievement and report any inquiries regarding approvals

or contracts or price lists to the concerned departments.

• • Medical

1. Revise the medical procedures with the diagnoses to check whether justified and correlated medically.

2. Ensure that the medical provider sticks to the operation procedures and card instructions for example: approvals are obtained if needed.

3. Differentiate between Chronic, critical, preexisting, acute and other cases based on the table of benefit and policies to ensure the alignment

with the set limits.

4. Review the medical history of each beneficiary to ensure the validity of the diagnosis and the procedures.

5. Match the diagnosis, provider medical procedures and ICD codes (International Classification of Diseases) on the system with the medical

history of the patient confirming adherence and correlation.

• Financial

6. Ensure the adherence of the claimed amounts to the medical procedures provided to the beneficiary who is already requested from the

physician.

7. Review the price of the medical procedures and compare it with the stated price lists to ensure that they are financially aligned.

8. Ensure that the agreed discount and co-payment are applied from the provider side according to the contract, operation procedures and the

medical card instructions.

• Performs other tasks as assigned (by line Manager) within the realm of his/her position, qualifications and capabilities.