The claims Quality supervisor will manage to deliver a quality provider statement free of technical and medical errors within the bounds of indicial policy, standard medical practice, and regulations, and take steps to improve the processes to this effect.

Key Responsibilities:

1- Inpatient Claims Operations

• Directly supervises the distribution and completion of the Inpatient claims adjudication process by the Senior Medical officers within the KPI
• Gets directly involved with provider claims above SR 100,000, and all claims where the adjudicators are unsure about the decision
• Coordinates with Pre-authorization, Provider Relations, HAD, and Clinical governance for issues identified at Impotent claims, and requires corrective actions
• Ensures smooth day-to-day Outpatient claims operations with the help of the Unit Sections Heads, who are directly involved with the team of Medical Officers
  

2- Outpatient class Operations

• Works closely with the Unit Sections Heads to maintain claims production considering the projected number of claims influx, available resources, and a minimum number of average times where needed
• Coordinates with the department manager, other departments, and with the team to implement project enhancements and policy changes in relation to business decisions

3- Medical Guidelines

• Maintains separate Claims Adjudication Guidelines documents for Inpatient and Outpatient workflows that align with the company's policy, business objectives, and CCHI regulations. The document will be updated at least annually for changes, and will serve as a reference guide for the claims adjudicators
• Communicates with other medical departments to ensure clarity for the adjudicators on the guidelines where needed
  

4- Fraud and Abuse

• Ensures an effective fraud and abuse identification and escalation mechanism, for the inpatient claims directly with the Senior Medical Officers, and for the Outpatient in liaison with the Medical Unit Section

5- Process Improvement.

• Identifies and discusses with the department manager system/workflow opportunities for process improvement and efficiency, and leads projects in the medical team to this effect
• Explains and clarifies statement rejection areas to aid the settlement process for the provider relations, where needed.

6- Quality Assurance

• Maintains internal monthly quality checks, with the help of a "quality squad" from within the team, for all adjudicators, and maintains an average of at least 95%, and provides a detailed monthly report of the team's quality to the department manager.
• Coordinates with the quality squad and Unit Sections Head for a monthly bulletin for the team with the detailed quality report, and important scenarios related to problem areas identified on the quality checks
• Recruits good quality candidates, and assures good training, evaluation and feedback during the probation period. Maintains a set of training material, and ensures that new-joiners gel in the team well.

Qualifications and Skills :

• Bachelors degree in Medicine (M.B;B.S./M.D or equivalent) from an accredited institution
• Clinical Experience
• Medical Insurance Experience in a middle management position
• 5- 10 Years Experience