Medical Claims Processing Supervisor
Walaa Cooperative Insurance CompanySaudi Arabia4 منذ أيام
الوصف الوظيفيAssist in implementing internal controls to ensure claims accuracy and prevent fraud, waste, and abuse. Coordinate with internal audit and compliance teams to maintain adherence to CCHI guidelines and regulatory directives. Contribute to training programs for staff and providers on correct claims submission and reconciliation processes. Oversee investigation of claim discrepancies, rejections, and denials, and ensure timely resolution. Support communication with healthcare providers, external and internal teams / stakeholders to address recurring issues. Escalate unresolved or high-impact discrepancies to the Senior Claims Manager with recommended solutions. Act as deputy contact point for healthcare providers, external and internal stakeholders and claims staff. Provide guidance to healthcare providers on claims processing requirements and Nphies compliance. Participate in regular meetings with hospitals, clinics, and pharmacies to strengthen provider relations. Prepare operational dashboards and performance reports for management review. Support process re‑engineering projects to reduce rejections and enhance claims accuracy. Team Oversight & Support : Supports the Manager in supervising daily claims intake, validation, adjudication, and settlement activities. Training & Development : Contribute to training programs for staff and providers on correct claims submission and reconciliation processes. Performance Management (Tactical) : Oversee investigation of claim discrepancies, rejections, and denials, and ensure timely resolution. Identify trends in denials and contribute to corrective action plans. Risk & Compliance Culture : Acts with due diligence to safeguard company interests. Maintain highest level of confidentiality. Hands‑on experience in Medical Claims Processing domain (3–5 years minimum) Healthcare Insurance & Regulatory Compliance (5+ years preferred) Understanding of Medical Claims Processing Integrity & Ethical Mindset – Strong moral principles to handle sensitive financial and healthcare data responsibly. Attention to Detail – Ability to spot anomalies, inconsistencies, and patterns in data. Analytical Thinking – Logical approach to problem‑solving and decision‑making. Critical Thinking – Evaluating evidence to determine fraud risks and compliance gaps. Persistence & Patience – Fraud investigations and reconciliations can be complex and time‑consuming. Communication Skills – Clear reporting of findings to internal teams, auditors, and regulators. Confidentiality & Discretion – Handling sensitive patient and financial information with care. Adaptability – Keeping up with evolving fraud schemes and regulatory changes. Fluency in Arabic language, working knowledge of the English language is an advantage. Proficiency in using Microsoft Office applications and database management. Ability to work independently and as part of a team to achieve network management goals.
About the job
Duties and Responsibilities :
Claims Processing Oversight
- Support the Manager in supervising daily claims / batch intake, validation, adjudication, and settlement activities.
- Ensure compliance with Nphies e-claims standards, coding standards, MDS and timeline specified per regulations.
- Monitor turnaround times (TAT) to meet internal and external service-level agreements (SLAs).
Quality Assurance & Compliance
Discrepancy Resolution
Stakeholder Management
Reporting & Continuous Improvement
People Management & Performance
This role is critical for the day‑to‑day leadership and performance development of the claims processing team, which is vital for a Tier 1 insurance company's operational excellence.
Skills
Education
Bachelor’s degree in Medicine / Pharmacy, Healthcare Administration, Business Administration or Health Informatics.
Experience
Personal Attributes / Skills
Others
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إنشاء تنبيه وظيفي لهذا البحث
Supervisor • Saudi Arabia