Manager - Medical Claims

Job Purpose:Process and evaluate all assigned medical claims efficiently and accurately, in accordance with the scope of coverage, provider contracts, and CHI/ IA regulatory requirements, while consistently meeting quality and turnaround-time standards. Key Accountabilities:

• Apply Claims Department policies, procedures, and quality standards.
• Process assigned claims with efficiency, maintaining agreed TAT and SLA for all batches, from creation through closing.
• Handle internal and external email communications professionally, following email etiquette and agreed SLAs.
• Ensure all adjudication decisions comply with CCHI regulations, Insurance Authority requirements, and Tawuniya internal policy.
• Review internal quality-review findings, address identified gaps, and implement agreed corrective actions.
• Contribute to the training and development of claims staff by sharing medical knowledge and processing guidelines.
• Provide structured feedback on system limitations, operational process gaps, and improvement opportunities.
• Support data-driven claims management and healthcare value initiatives, including VBHC, DRG and PHM to identify utilization trends, improve quality and appropriateness of care, optimize healthcare costs and support continuous improvement.
• Provide medical claims data analysis to identify utilization patterns, cost drivers, abnormal trends and potential areas of leakage or overutilization.
• Deliver assigned KPIs and drive continuous improvement through quarterly Kaizen initiatives and OPLs.
• Pursue individual technical, personal, and medical skills development against the agreed capability-building plan. Qualifications, Experience & Skills:
• University degree in MBBS; A Master degree is a plus. Minimum Experience:
• 1 year of experience in medical field. 4 - 5 years of experience in insurance industry preferably in medical claims.