Job Purpose:
To manage medical operation activities in a robust approach in line with the organization strategy and Oman regulations, this is to ensure meeting clients expectations and providing a World Class Customer Service experience throughout the process.
Main Accountability:
Adjudicating and processing complex inpatient pre-approvals cases following best medical practices and claims handbooks within the agreed TAT per line of business
Implementing Case Management concept to hand hold members in their medical journey and ensuring proper treatment plan is being provided based on first class medical protocols
Arrange Second medical opinions and provider support on complex cases using regional capabilities if not found available locally
Performing onsite audit activities in liaison with the central FWA unit, subject but not limited to the following scenarios:
o Medical records audits for Inpatient ongoing case
o Malpractice investigations
o Retrospective open file reviews
o Undeclared pre-ex conditions onsite investigation
Evaluate reimbursement complex claims which requires in-depth review of medical assessment and/or further onsite investigations
Keeping up to date with latest regulatory changes liaise with other internal stake holders to ensure implementations are within scope.
Assist Chief Medical Officer in regulatory escalations, providing required information for cases re-assessment
Supervising the Medical board executive in achieving required level of maturity in medical board management inline with the set objectives of the role
Strictly maintain the quality and client SLAs
Essential Requirements:
Holder of a Medical degree
Good analytical skills
Strong Adjudication skills
5 Years of experience in insurance and TPAs
Customer-focused
Strong communication (verbal & written)
Team management or leadership skills
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