Evaluate the medical necessity and consistency of diagnosis and procedure stated on the claims according to accepted international guidelines and guidelines for the specific country.
Evaluate authorization / extension requests for complex hospitalization cases (mainly from US and Europe).
Process, evaluate / adjudicate and audit within the agreed timeframe and with the expected quality.
Contribute in developing, updating and implementing international guidelines
Effectively liaise with providers, member and other stakeholders (answering phone calls, replying to emails etc.) in a timely and professional manner
Support the claims adjudicators and case managers in dealing with complex medical related enquiries, reviewing medical reports and selecting suitable medical providers and conducting occasional follow up calls with the medical providers to check deviations in the scheduled treatments.
Participate in special projects, preparation of reports and presentations.
Lead discussion with medical providers and clients regarding the medical trends and guidelines.
Actively propose new initiatives to control medical costs.
Work shift wise as required
Good command of written and spoken English; knowledge of Arabic and additional languages (French, Spanish, German, Korean) is an advantage
Good knowledge of international guidelines and regulations
Good analytical, execution, problem solving and decision making skills
Flexible and able to work under pressure
Respect and maintain a high level confidentiality
Proactive and results oriented whilst ensuring high quality of work
Advance level of customer service orientation and professionalism in all interactions
Able to work in a multi-cultural environment and promote teamwork and knowledge sharing in order to achieve goals and deliverables
Job Description. Evaluate the medical necessity and consistency of diagnosis and procedure stated on the... Support the claims adjudicators and case managers in dealing with complex medical related enquiries...
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