Jobs / Data Analyst Jobs / Medical Claims Adjudicator Manager – Utilization & SIU Analyst

Medical Claims Adjudicator Manager – Utilization & SIU Analyst

Yodawy - Egypt - Giza
Experience: 5 to 8 years
Salary: Confidential
Employment: Full Time
Education: Not Specified","translations":{"name":{"ar":"غير محدد","en":"Not Specified
  • Job Summary: 
    We are seeking a highly skilled Medical Claims Adjudicator with strong expertise in
    utilization data analysis, medical and financial rules, and fraud, waste, and abuse
    (FWA) detection. The role is responsible for accurately reviewing, analyzing, and
    adjudicating medical claims (inpatient and outpatient ) in compliance with medical
    policies, medical rules, reimbursement rules, and regulatory requirements, while
    proactively identifying abnormal utilization patterns and potential fraud or abuse cases.

    Key Responsibilities:
  • Review, analyze, and adjudicate medical claims in accordance with:
  • Medical policies and clinical guidelines
  • Utilization management rules
  • Contractual and financial rules
  • Perform utilization data analysis to:
    o Identify overutilization, underutilization, and inappropriate services
    o Detect unusual provider or member behavior patterns
    (constellations/pattern analysis)
  • Apply medical coding and billing rules (e.g., ICD, CPT, HCPCS….).
  • Validate medical necessity, appropriateness of care, and level of service
  • Analyze claim trends and utilization metrics to support cost containment and
    quality assurance.
  • Identify, document, and escalate suspected fraud, waste, and abuse (FWA)
    cases in line with internal protocols.
  • Ensure compliance with regulatory requirements, payer policies, and internal
    SOPs.
  • Prepare clear documentation, reports, and recommendations related to claim
    decisions and FWA findings.
  • Support audits, internal reviews, and continuous improvement initiatives.
Apply on the Job Website
Post date: Today
Publisher: Wuzzuf .com
Post date: Today
Publisher: Wuzzuf .com