Medical Claim Senior Assessor

Key responsibilities / what you do:

Review and assess medical claims for both inpatient and outpatient services to determine coverage eligibility and compliance with policy terms.
Validate diagnosis-related group (DRG) coding for inpatient admissions using ICD-10-CM and CPT standards, ensuring alignment with clinical documentation.
Apply thorough knowledge of UAE healthcare billing regulations, including DHA, DOH, and MOH guidelines, to ensure claims meet local compliance standards.
Identify and rectify incomplete or inaccurate claim submissions. Ensure all required documentation is present and properly coded aligning with policy guidelines.
Notify payers regarding claims that exceed predefined financial thresholds, ensuring timely communication and resolution.
Track and maintain both quantitative (volume) and qualitative (accuracy) metrics for claims processing.
Achieve assigned daily processing targets while maintaining high levels of accuracy and efficiency.
Collaborate with internal departments to resolve claim-related queries.
Perform other responsibilities as assigned by the department lead, in line with the scope of the role.