Insurance Doctor

Overview

The insurance doctor is responsible for managing all insurance-related activities for the hospital, ensuring that medical claims are accurate, compliant, and processed efficiently to maximize reimbursement and minimize denials. It is a hybrid role combining clinical knowledge, insurance expertise, data analysis, team leadership, and process improvement.

Responsibilities

• Evaluate and process claims in accordance with insurance policy, terms and conditions, and MNGHA policies and procedures. Review medical reports and ensure proper entry and compatibility with the services provided by the hospital.
• Check the accuracy of medical information with supporting documents (i.e., laboratory, pharmaceutical, radiology, etc.).
• Communicate with the treating physician / medical team for any clarification or completion of missing information.
• Escalate pending cases to the concerned department and follow up directly with Medical Services. Coordinate and follow up with the approving officer(s) on discrepancies in the official form.
• Collaborate with the claims section team on clinical queries / requests to reassess the claims.
• Collaborate and communicate with insurance company representatives, such as claims adjusters or medical reviewers, to provide additional information or clarification about the medical services provided.
• Develop a billing system to improve Revenue Cycle Management (RCM) and decrease the number of rejections. Report any observations related to claims that may affect the RCM.
• Facilitate the reconciliation process, respond to rejected claims with proper justifications in accordance with the insurance requirements, and coordinate with the insurance companies for resubmission in a timely manner.
• Participate in establishing, developing, and implementing guidelines to evaluate and process medical claims.
• Assuring requires preauthorization or prior approval for specific treatments, procedures, or medications.
• Collect sufficient information for each issue and escalate it to the concerned department.
• Provide professional advice to subordinates on all aspects of medical insurance practice and law.
• Assume the responsibilities of Claims Analyst as and if required.
• Prepare and present necessary reports and correspondences as required by the Executive Management and Senior Executive Management.
• Perform other job-related duties.

Key Result Areas

Qualifications

Technical Skills

Behavioural Skills

Seniority level

Employment type

Job function

Riyadh, Riyadh, Saudi Arabia 10 hours ago

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