Medical Claims Doctor

Review medical claims for accuracy, completeness, and medical necessity.

Assess diagnosis, treatment plans, investigations, and procedures against clinical guidelines.

Verify insurance coverage and policy eligibility.

Approve, reject, or recommend modifications to medical claims based on medical justification.

Review pre-authorizations and post-treatment claims when required.

Communicate with treating physicians to obtain additional clinical information when necessary.

Coordinate with insurance companies regarding claim approvals and medical inquiries.

Ensure compliance with hospital policies, insurance regulations, and clinical standards.

Identify inappropriate billing or potential fraud and report findings.

Maintain complete and accurate documentation of claim reviews.

Prepare medical review reports and performance statistics.

Participate in quality improvement initiatives related to claims management.

Perform any other duties assigned by the direct manager.

Education Bachelor's Degree in Medicine and Surgery (MBBS/MBBCh).

Valid medical license.

Experience 2–4 years of clinical experience.

Previous experience in Medical Claims, Utilization Review, Health Insurance, or Medical Approvals is a Must.

Technical Skills Knowledge of medical coding concepts (ICD/CPT is an advantage).

Understanding of health insurance policies and claims processing.

Familiarity with Hospital Information Systems (HIS).

Good Microsoft Office skills.

Competencies Strong clinical judgement.

Analytical and critical thinking.

Attention to detail.

Decision-making skills.

Communication and negotiation skills.

Problem-solving ability.

Time management.

Integrity and confidentiality.

Ability to work under pressure.

Languages Arabic: Native.

English: Good command (written and spoken).