Medical Claims Officer

4 weeks ago

Muscat, Muscat, Oman Nextcare Full time
Key responsibilities/What you do:
  • Precertification team is functional on 24/7 basis. Therefore, the Medical Officer will be working on flexible shift basis as per the schedule provided by the Team Leader.
  • Adjudicates Cases, authorizes decision within the stipulated turnaround time & with the highest quality standards in view with the policy terms and conditions.
  • Performing complete file review with regards to the multidisciplinary notes, TPR charts, physician order's notes, lab reports, radiology reports, drug chart sheets, consultation notes, nursing notes, progress notes, etc.
  • Requesting any medical documentation or finding any missing document which is essential in decision making.
  • Performing review of DRG Severity of Illness (SOI) in line with revision of CPT codes / ICD codes, which are being up-coded by the provider – if required discussion with the treating doctor and the medical coders.
  • Performing utilization review for DRG cases and FFS cases with regards to and not limited to final bill review + consumables mark ups + non covered item/services + overutilization of services.
  • Performing review of claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA, DOH/HAAD, MOH).
  • Adhering to the cost containment protocols for medical management cases.
  • Referring cases for second opinion when deemed necessary to confirm the best mode of management – also for cost containment to lesser Negotiating factor (NF) facilities within the member's network or option for home country treatment.
Key requirements/What you bring:
  • Bachelor's of Medicine (MBBS) with 1 year of clinical practice OR Bachelor of Nursing.
  • 1-2 years medical experience (reputable insurance provider, broker or a TPA experience a plus).
  • Knowledge of overall insurance industry practices is a plus.
  • Legally permitted to work in the country of operations.
  • Physically fit to carry out duties.
  • Fluency in MS Office (Excel, Word, Outlook, PowerPoint) and general internet navigation and research skills.
Key benefits/What we offer:

Our employees play an integral part in our success as a business. We appreciate that each of our employees are unique and have unique needs, ambitions and we enjoy being a part of their journey.

We are there to empower and encourage you with your personal and professional development ensuring that you take control by offering a large variety of courses and targeted development programs. All that in a global environment where international mobility and career progression are encouraged. Caring for your health and wellbeing is key priority for us. This is why we build Work Well programs to providing you with peace of mind and give the flexibility in planning and arranging for a better work-life balance.

Allianz Group is one of the most trusted insurance and asset management companies in the world. Caring for our employees, their ambitions, dreams and challenges, is what makes us a unique employer. Together we can build an environment where everyone feels empowered and has the confidence to explore, to grow and to shape a better future for our customers and the world around us.

We at Allianz believe in a diverse and inclusive workforce and are proud to be an equal opportunity employer. We encourage you to bring your whole self to work, no matter where you are from, what you look like, who you love or what you believe in.

We therefore welcome applications regardless of ethnicity or cultural background, age, gender, nationality, religion, disability or sexual orientation. Join us. Let's care for tomorrow.
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