Medical Claims Officer

4 weeks ago

Muscat, Muscat, Oman Nextcare Full time
Key Responsibilities / What You Do:
  • The precertification team operates 24/7; therefore, the Medical Officer will work on a flexible shift basis according to the schedule provided by the Team Leader.
  • Adjudicate cases, authorize decisions within the stipulated turnaround time, ensuring the highest quality standards in accordance with policy terms and conditions.
  • Perform comprehensive file reviews, including multidisciplinary notes, TPR charts, physician orders, lab reports, radiology reports, drug charts, consultation notes, nursing notes, and progress notes.
  • Request any necessary medical documentation or identify missing documents essential for decision-making.
  • Review DRG Severity of Illness (SOI) in line with CPT and ICD code revisions, including discussions with treating doctors and medical coders if required, especially in cases of up-coding by providers.
  • Conduct utilization reviews for DRG and FFS cases, including final bill review, consumables markups, non-covered items/services, and overutilization of services.
  • Review claims according to CPT and ICD coding guidelines, complying with insurance regulators (DHA, DOH/HAAD, MOH).
  • Adhere to cost containment protocols for medical management cases.
  • Refer cases for second opinions when necessary to confirm the best management approach, including cost containment strategies such as negotiating with NF facilities within the member's network or considering treatment in the member's home country.
Key Requirements / What You Bring:
  • Bachelor's of Medicine (MBBS) with 1 year of clinical practice OR Bachelor of Nursing.
  • 1-2 years of medical experience; experience with reputable insurance providers, brokers, or TPAs is a plus.
  • Knowledge of the insurance industry practices is advantageous.
  • Legally permitted to work in the country of operations.
  • Physically fit to perform duties.
  • Proficiency in MS Office (Excel, Word, Outlook, PowerPoint) and strong internet research skills.
Key Benefits / What We Offer:

Our employees are integral to our success. We recognize the unique needs and ambitions of each individual and support their journey through various development programs and courses. Our global environment encourages mobility and career growth. We prioritize your health and wellbeing through Work Well programs, providing flexibility for work-life balance.

As part of Allianz Group, one of the world's most trusted insurance and asset management companies, we are committed to caring for our employees and fostering a diverse, inclusive workplace. We welcome applications from all backgrounds, regardless of ethnicity, age, gender, nationality, religion, disability, or sexual orientation. Join us and help shape a better future for our customers and the world around us.

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