Job Description

PHCC has a vision to be the leader in transforming the health and wellbeing of people’s lives in Qatar. PHCC’s mission is to deliver comprehensive, integrated and coordinated person-centered health care services in the community through focusing on disease prevention, healthy lifestyles and wellness. In partnership with our stakeholders, we will improve the health and wellbeing of our population.

The incumbent will contribute to the organization by taking responsibility for providing support to clinical audit projects that are aimed to ensure that optimum care is delivered to our patients.

Key Accountabilities & Duties:

• Audit submitted and resubmitted claims for accuracy, completeness, and compliance
• Examine claim data, medical records, and billing patterns to find trends and discrepancies
• Audit claim payments to confirm correct reimbursement based on payer contracts and fee schedules
• Identify incorrect payments, underpayments, overpayments, or contractual discrepancies
• Establish sampling and scoring methodology of conducting these audits
• Verify correct use of mandated coding standards
• Conduct periodic review of the work performed by managed business operations vendor
• Detect billing discrepancies, contract misinterpretation, coding errors, documentation gaps, fraudulent billing, waste, overpayments, and processing errors
• Flag claims with potential for denial or underpayment
• Monitor success rate of corrective measures introduced by internal and external teams based on feedback rendered
• Ensure claims meet regulatory standards (MoPH, payer policies, etc.)
• Monitor adherence to internal policies and procedures
• Support external audits and regulatory reviews
• Monitor compliance of Managed Business operations vendors against their own standard operation procedures, guidelines and manuals
• Prepare detailed audit reports with findings and recommendations
• Share constructive feedback with internal / external end users to ensure appropriate corrective action is taken to eliminate errors
• Present audit outcomes to all stakeholders
• Track success rates of submitted and resubmitted claims
• Recommend system enhancements, rules development or workflow changes with relevant teams internally / externally
• Support performance dashboards, metrics reporting, and quality improvement initiatives
• Conduct training sessions for claims examiners and staff on proper claims processing, documentation requirements, and audit findings.
• Provide input into claims processing policies and SOP improvements
• Demonstrate proactive approach to patient safety by thinking what might go wrong in all your undertakings and take necessary measures to prevent them from happening.
• Identify and report potential or actual patient safety concerns, errors and/or near misses in timely manner.
• Follow patient safety-related policies, procedures and protocols.
• Demonstrate as sense of team work and effective communication.
• Partner with line manager to understand risks in your area of work, develop a plan on how to mitigate those risks, and develop shared accountability for implementing and evaluating the plan.
• The incumbent will undertake any such appropriate duties or responsibilities as directed.
• Ensure high standards of confidentiality to safeguard any sensitive information.

Education Requirements: Bachelor’s degree in healthcare/clinical, Business, finance or related field

Certification, license or training Requirements: Certificate in Clinical Audit or Quality Assurance is preferred

Experience & Knowledge: Minimum of 5 years of experience in medical claims adjudication, or claims auditing