Medical Reviewer
About the company
As a member of Munich Re, the MedNet Group is a leading third-party administrator across the MEA region. We are currently seeking to hire a Medical Reviewer - Medical Care Unit, who will be responsible for providing services related to medical evaluations/authorizations for in-patient and outpatient insured members/providers and handling queries relating to pre-approvals.
Your tasks
Evaluate and assess the healthcare needs of clients, including reviewing medical records, insurance policies, and treatment plans by active collaboration with healthcare providers and clients.
Assess risk exposure of members in line with medical underwriting policies.
Evaluate cases to achieve optimum member satisfaction, adhere to strict turnaround times (TATs), and manage cost-containment via prescribed maneuvers like DRG debates.
Quickly and accurately manage queries from providers, insurance companies, and insured members relating to approvals.
Provide medical guidance to the claims department staff and assistance in accurate coding, add-on/LTC reviews.
Deliver excellent customer service to insurance companies and insured members with a view to achieving maximum client satisfaction.
Case management and attending hospital visits to investigate claims to minimize fraud and abuse.
Compile data and prepare monthly statistical reports to monitor departmental performance and medical trends.
Requirements
- Medical degree (MBBS or equivalent) from a school recognized by the WHO.
- 2-3 years of experience in medical claims evaluation, in-patient approvals, or case management preferably from TPA or MSO organizations in the insurance sector.
- Certified medical coder (CPT/ICD/DRGs) with relevant experience in DRG debates and severity negotiations.
- Industry knowledge related to the local healthcare services system.