Medical Claims Officer

2 weeks ago

Muscat, Muscat, Oman Nextcare Full time
Key responsibilities/What you do:
  • The Precertification team operates on a 24/7 basis. Therefore, the Medical Officer will be working on a flexible shift basis as per the schedule provided by the Team Leader.
  • Adjudicates cases and authorizes decisions within the stipulated turnaround time while maintaining the highest quality standards in accordance with the policy terms and conditions.
  • Performs complete file reviews regarding multidisciplinary notes, TPR charts, physician orders, lab reports, radiology reports, drug chart sheets, consultation notes, nursing notes, progress notes, etc.
  • Requests any medical documentation or identifies any missing documents essential for decision-making.
  • Performs review of DRG Severity of Illness (SOI) in line with revision of CPT codes / ICD codes and discusses with the treating doctor and medical coders if required.
  • Conducts utilization reviews for DRG cases and FFS cases concerning final bill reviews, consumables markups, non-covered items/services, and overutilization of services.
  • Reviews claims as per CPT and ICD coding guidelines in line with insurance regulators (DHA, DOH/HAAD, MOH).
  • Adheres to cost containment protocols for medical management cases.
  • Refers cases for second opinions when deemed necessary to confirm the best mode of management and for cost containment to lesser Negotiating Factor (NF) facilities within the member's network or options for home country treatment.
Key requirements/What you bring:
  • Bachelor's of Medicine (MBBS) with 1 year of clinical practice or a Bachelor of Nursing.
  • 1-2 years of medical experience (experience with a reputable insurance provider, broker, or TPA is 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 is unique, with unique needs and ambitions, and we enjoy being a part of their journey.

We empower and encourage you in your personal and professional development, offering a large variety of courses and targeted development programs. All this occurs in a global environment where international mobility and career progression are encouraged. Caring for your health and well-being is a key priority for us. This is why we build Work Well programs to provide you with peace of mind and 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 makes us a unique employer. Together, we can build an environment where everyone feels empowered and confident to explore, grow, and 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, regardless of your ethnicity or cultural background, age, gender, nationality, religion, disability, or sexual orientation. Join us. Let's care for tomorrow.
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