Team Leader-Reimbursement Claims

The job holder is responsible to supervise the Reimbursement claims team, monitor output levels, assist processing medical claims in a timely efficient manner and has an overall responsibility of the proper evaluation, processing, auditing and reporting of outpatient reimbursement claims.

Key Job accountabilities are as follows:

• Supervise and monitor the daily target of the reimbursement team, TAT of Reimbursement claims, Quality of processing, and other Key performance indicators set by the management.
• Ensure accurate application of applicable rates for reimbursement according to the Network, schedule of benefits, correct allocation of benefits, collection of deductibles/copayments, observance of policy limits and adherence to claims submission protocols.
• Data entry and adjudication of Reimbursement claims accurately
• Forward approved claims once processed to PICs for their acknowledgment.
• Forward Electronic bordereau of the E- claims to the payers to inform them of approved claims and settlement amounts
• Send weekly and monthly processing reports to clients for their records.
• Answering provider, insured members and PICs queries via phone calls and emails, regarding claims processing, coverage limit inquires and any other inquiries to provide them with clarifications where needed.
• Monitor the performance of the team members and provide them the required training in order to improve their technical, medical, insurance skills and knowledge, improve the quality and efficiency of performance, enable them to fulfill special tasks and achieve set targets, daily duties and responsibilities.
• Train new hire processors or current processors where needed to insure they are capable of doing their job.
• Take a leading role in developing, updating and implementing guidelines for processing and reporting of claims.
• Review and audit the reimbursement claims processed by following the auditing criteria, guidelines and applying the high costs authority matrix when needed.
• Coordinate with the Quality Assurance Department to ensure best quality level of claims processing by ensuring error corrections and error rates
• Manage holidays, leaves and monitor attendance so as to keep the department functioning in its full performance capacity.
• Report Fraud and abuse cases.
• Organize, attend and document meetings with internal and external groups.
• Consistently, efficiently and effectively work to achieve the daily targets and the initiatives.
• Ensure that the company policies and procedures are followed by the reimbursement claims team.
• Ensure that business decisions and processes are documented in a professional way and the communication requirements are being adhered to in a timely manner.
• Ensure that the team delivers high quality of customer service and respects medical and work ethics at all times.
• Conduct training sessions for PICs/Brokers/Insured Groups.

Minimum Qualifications:

• Graduate of any paramedical Bachelor Degree
• Master's degree in paramedical field is a plus point

Minimum Experience:

• Minimum 2 years of experience in Reimbursement claims processing in MedNet.
• Minimum one year of experience in managing a claims team in health insurance
• Good business understanding and background

Job-Specific Knowledge & Skills:

• Computer literate and excellent knowledge of Microsoft applications
• Excellent communication, negotiation, presentation and interpersonal skills
• Good command of written and spoken English language, Arabic knowledge is an added advantage
• Good analytical, planning, execution and conflict solving skills
• Basis knowledge of relational databases

Competencies Required:

• Result Oriented team leading skills
• Leadership skills, People development and management skills
• Ability to work under pressure
• High Standards of Quality of work
• Support of diversity
• Customer service
• Attention to details