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 Weekly / Monthly Claims Processed

Coding & Documentation Accuracy

Query Resolution Time

Reduction in Missing Information

Reduction in Pending Cases

Timely Resubmission

Reduction in Write-offs

Timeliness and accuracy of financial reports produced

Number Reporting breaches identified

Consolidations, Reporting & Analysis

Qualifications Degree in Medicine or equivalent

Technical Skills Knowledge of CBAHI, Ministry of Health care policy and procedure.

Knowledge of the health care sector.

Knowledge of Medical coding, billing process and Clinical Documentation for RCM

Clinical Understanding

Work-stream leads, subordinates, healthcare team, physicians, insurance companies

High paced environment with intense deadlines

Great deal of details and accuracy

Behavioural Skills Attention to Detail

Professional Communication

Analytical Skills : Ability to analyse denial trends and identify root causes

Problem-Solving : Proactive in creating solutions to prevent future claim rejections

Persistence & Follow-up : Tenacity in managing the appeals and resubmission process.

Business Acumen

Strategic Thinking

Leadership Skills

Ethical and Personal Integrity

Seniority level

Mid-Senior level Employment type

Full-time Job function

Health Care Provider Industries : Medical Practices Riyadh, Riyadh, Saudi Arabia 10 hours ago

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